Key strategies for successful integration of nurse practitioners (NPs) into critical care units include defining and implementing the role of NPs, providing options for orientation, and supporting and training novice NPs, according to a report in Critical Care Nurse

Appropriate planning for role implementation begins with conducting a needs assessment to determine what the provider need is, define the model of care and NP role, and plan implementation of strategies, stated Shari Simone, DNP, from the University of Maryland Medical Center, and colleagues. Determining the full-time NP positions needed in an intensive care unit (ICU) depends on the type of ICU, the care delivery model, patient acuity levels, and providers’ responsibilities. Depending on the patient population and acuity level, the provider-to-patient ratio varies from 1 to 4 to 1 to 8 during the day and 1 to 10 at night. Deciding on the work model and hours of coverage is based on the role of the NPs at the unit.

An advanced practice leadership model helps to address the challenges of whom to hire and how to successfully orient NPs into the ICU team, noted Dr. Simone. Having a lead NP helps organize the process of recruitment, interviews, orientation, and integration into the unit, role development, and performance management. All NPs should be credentialed to practice to their full scope as allowed by the organization’s medical staff bylaws. Providers who are unaware of recruitment and training needs for new NPs in ICUs can benefit from orientation programs.

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Training Curriculum

Development of a structured, comprehensive orientation program is a key component to ensuring successful integration of NPs. According to Dr. Simone, programs should include standardized didactic sessions, high-fidelity simulation, and procedural education, as well as weekly educational and networking opportunities to NP fellows.

A competency-based orientation program was designed to provide a standard process, establish clarity about expectations of orientation, improve accountability for oversight and organization of content, and streamline the workload for the leadership team and preceptors. Orientation is 12 to 26 weeks long, depending on the competency expectations and the individual NP‘s knowledge needs.

Postgraduate training programs have rapidly emerged in all specialties, including critical care, to either increase the knowledge and breadth of clinical expertise of NP students or to improve the transition of entry-level NPs into practice. The NP fellows are supervised by an NP or physician preceptor and are not credentialed to practice independently until they have successfully completed the program.

Evaluation and feedback

Evaluation of clinical performance and ongoing feedback ensure achievement of basic competence during orientation and continued professional growth, noted Dr. Simone. Key evaluation components include a standardized competency assessment and weekly evaluation during orientation, ongoing professional practice evaluation (OPPE), focused professional practice evaluation (FPPE), and an annual 360-degree performance evaluation.

According to Dr. Simone, “Informal and formal mentorship is a critical thread in all aspects and stages of professional development of NPs and can positively affect satisfaction and retention. The relationship between a mentor and NP fellow cannot be successful without effective communication that is respectful and open and involves ongoing dialogue, sharing of knowledge, and constructive feedback.”

Promoting collaborative, team-based care also requires a commitment to shared mentoring of novice fellows, NPs and residents by physicians, experienced fellows, and NPs. This culture must support a cooperative, shared leadership with overlapping competences and various shared degrees of responsibilities between fellows and NPs, according to Dr. Simone. In addition, she stated, NPs working in critical care units must be held to the same professional expectations, such as journal club presentations, attendance at educational offerings, conference presentations, and participation in research and quality improvement projects.

Understanding the importance of appropriate role use, knowledge and skill expected, comprehensive training programs, and continued professional development are necessary to realize the contributions of nurses in critical care, concluded Dr. Simone. 


  1. Simone S, McComiskey CA, Andersen B. Integrating nurse practitioners into intensive care units. Crit Care Nurse. December 2016. doi: 10.4037/ccn2016360