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A Day in the Life: ICU NP

We had the pleasure of interviewing Ms. Teddie Tanguay, Past President of the NPAA, an NP in the Royal Alexandra Hospital Intensive Care Unit. The goal of our interview was to understand some of the complexity of the NP role in this setting, what drives NPs to specialize in this area, and how the Nurse Practitioner profession can be advanced through the work that is being done by Teddie and other NPs like her.

Teddie Tanguay, NP

What prompted you to consider moving into an Advanced Practice role in Nursing? 

I’ve been in critical care for a lot of years, and I was attracted to critical care because it was a place where RNs could have a lot of autonomy, lots of skills. It is always challenging, you learn something new every day.  But you do get to that plateau where you’re the expert RN, you kind of have it down. I was a charge nurse and did the day to day running of the unit. And I found myself wanting to have something to grow into, wanting to have more impact on patients’ day to day care, and how they were looked after in the ICU.

How did you make the transition from RN work through your advanced degree and into NP practice?

I went into the program in 2000, graduated in 2003. Before that time there was only one critical care NP in the city, and that was with CVICU, who had begun her program in the 90s. They were just starting to look at NPs in the region. Until that point, there really wasn’t an opportunity to do a clinical Masters, and I wouldn’t have gone back to do a Masters degree to be a manager. When the opportunity came up to pursue a clinical Masters I jumped at the opportunity. The Grey Nuns was just reopening their ICU and needed a whole orientation program designed – essentially retraining on how to run an ICU. The only reason I took the job is that they were looking at hiring a nurse practitioner in their ICU and we agreed that I would get their ICU and dialysis program up and running, and then I would go back to school and I would be their NP after graduation. So I started school, and the Nuns lost their funding a year into my program. I called my director friend here at the Alex, where I’ve worked most of my life, and said that I needed to come as a student to finish my hours. They took me as a student, and then we had a discussion about what we thought the role could be. My colleague said, “well I know what *you* want to do, Teddie”.  They had me pegged! I had been his charge nurse and unit manager for many years and had already been running things. So the Alex ICU took me over, and at the end of the year they hired me right after I finished my program.

What extra training did your current position require over and above your NP program?

There was a lot of thought put into how we would interact in the unit coming in, what we would be responsible for, and you wouldn’t even recognize what we do now, versus what we did when we started. There was one NP here initially, and she would round on 4 chronic patients on the B side of the ICU which weren’t weaning off of the vents. She worked Monday to Friday, 8 hour days. Once I started there was a gradual increase of the type of work we did and the hours that we were able to cover. Since I found myself bored after the basic rounding on the B side, I would go into other areas of the ICU and “meddle”. We also gradually worked ourselves into floor consults, and started to work weekends and evenings, lessening the clinician workload on those other shifts. We take a variety of patients on the B side, do admissions, consults, insert lines, and serve as a major support to the ICU residents. Now, when a new NP is hired in our ICU there is a 4-6 month orientation, where they do straight days, then we put them on evenings, and then they learn the admissions, consult stuff. Eventually we put them into the regular rotation. Currently we have 6 NPs on staff.

Describe one significant learning about the role of the NP within your current practice environment.

You have to have excellent communication and collaborative skills to work in a team. You have to always want to be learning; to have the initiative to look into something and learn what you don’t know. To be safe you have to be able to recognize your limitations and call when you need help. If you don’t ask, everyone gets into trouble.

How does your role fit within established health care roles in your work area? 

I think that we are seen as leaders in the unit. Many times the nurses feel more comfortable talking to us than the intensivists, because we’re not seen as intimidating, right? They’ll come to us, even if it’s not our patients. They’ll come to us for advice. 

At work in the ICU

I think we are seen by the rest of the team as responsible key members. When we first started, not everyone was on board, so we needed champions. We were fortunate that the champions we had were ICU leaders, so they were not scared to take on staff who weren’t supportive. It was clear from the beginning that this was a unique NP model, and that there was a mandate to make it work. We did a lot of work at the beginning to make sure all of the interprofessional team members understood what our role was going to be, and the role has continued to grow. It was also clear that our primary goal was to improve care for patients –  input into the long term stays so that the care was consistent, reducing the week by week changes as the new intensivists rotated through on their every eight week schedule, that sort of thing.

Another unexpected role was that of educator to other learners. Those learners (as well as the staff) don’t know what we can or can’t do – they forget. You need to remind them! Residents eventually realized, “this is a resource, this is somebody who can help who isn’t evaluating me!”. We were the safe guys for them to come and ask a stupid question to. By the time we were 2-3 years into the model, they would search us out when they arrived for their rotation. We often heard: “I actually asked to come to the Alex, because I heard that this was the place to go. There’s help on shift with patient admissions and we’re not left on our own”. 

What is one challenge you didn’t realize you would face when starting in your current position? 

I think the biggest challenge now is working to sustain an NP ICU model. As time has gone on every program is starting to face this concern. Most of us [the ICU NPs] are lifers when we get the position, and there’s not a huge casual pool to feed into the system. We often say “Oh my god, we can’t lose anybody!” We’ve managed to get to the point where we’re irreplaceable, which was our goal. We thought that the model would also, then, be irreplaceable. Now we are hoping to grow it, and spread it to the entire Edmonton Zone.

Along with this is the much bigger issue in acute care – Tier One medical coverage. As the service percentage of the resident education is decreasing, there are huge gaps in the hospital setting. Residents work hours have been reduced, and classroom time increased, so they are not available for service hours providing coverage. NPs can be the answer to this problem, if leadership makes it possible.

What research or teaching are involved in your current role?

The NP team has two retreats a year where we determine what we’re going to work on – whether it’s quality, research, teaching or leadership. We try to cover all of the domains. But we clearly understood in the beginning that each of those domains are a full time job, and clinical for us is always first. We’re hired for clinical. What we  decided was that we would each take a domain that is of interest to us, and work on this in our office time. One NP is very good at research, I do all of the orientation/planning/student work, more of the leadership end. We have NPs who take on quality projects. Hopefully we provide an example of the whole NP role within our ICU NP team.

What is something that all NPs can learn from the work you are doing in your current environment?

I think every NP can work on taking symptoms and coming up with a list of  differentials. It doesn’t matter what your practice area is, you will have your list. It is so important to have that framework, how you approach the meat and potatoes of what your problems are. That’s the thing that we try to impart to our new staff/learners. It’s how NPs in any area think through problems; the systematic manner in which you approach a patient. I’ve learned that if you don’t follow that organized plan, you miss something. For sure, as time goes on, you get better at standardizing your assessment. In the beginning you end up going in to the room four times because you forgot something. “Hmm, he could have an ischemic gut. Did I do a good abdominal assessment? Nope. Better go back in there and see if he has peritonitis”. 

How can the NPAA support NPs working in your practice area?

I think the NPAA has started to realize that there are many practice areas, and that NPs are valuable in all of them. They can look at the gaps in primary care, acute care or LTC, and say “here’s an opportunity for NPs to help improve care”. In acute care it’s Tier One medical coverage, and the NPAA can back up NPs in acute care by advocating for NP capacity in this area . If NPs are going to say that we provide excellent care, and benefit our patients, it isn’t just Monday to Friday! My patients are here 24/7. Some of the most critical times for them are actually at 3 am, when there isn’t a big-gunned intensivist around. Even with the junior resident, that’s the time when I help most. When the two of us go on a consult, and they can’t get an airway, I’m there. Or if they don’t understand that a patient is sick, I can say “this guy is really sick, you call the intensivist and tell him that we’re bringing him downstairs right now!” If NPs aren’t providing that kind of coverage, the patient is losing out.

What is one thing that you think NPs should be pursuing, as a group of professionals working towards the future of healthcare in AB?

I think they should advocate that NPs could be a method of system transformation. That we could be a cost effective solution to care. To do this the NPAA has to commit to the value of every area of NP practice. There’s no work environment that is better or worse than another. We are here to meet the needs of our patient populations, and all of us are doing it well. However, we all need to decide that we are together in this. No one group is big enough to do it on their own. We all have the same legislative issues, and we need to fight them under one NPAA banner. The government doesn’t want us merely to expose problems, they want us to propose solutions. The NPAA can develop solutions and bring them forward with one voice, on the behalf of NPs across Alberta.

Editor: Thanks Teddie, for your experience, candor, and for pushing Nurse Practitioner practice forward in Alberta.