Orthopedic FNP Texas - page 2

by littlebelle1293 3,711 Views | 17 Comments

Hello all I'm currently in the FNP program at Texas Tech, due to graduate in August and trying to figure out what to do afterwards. My background is ICU for 2 years and Ortho for the last 3 years. I always thought I would go... Read More


  1. 1
    Quote from littlebelle1293
    Thanks TX RN,
    I too have seen the same thing in Austin hospitals. While I don't feel that I would be prepared to see inpatients based on Texas Tech's FNP program, there are others who have better experiences or additional education that could give them that ability.

    Core0, I can't seem to understand why an FNP working in the clinic setting only (no inpatient no OR) of an orthopedic practice would be working outside of their scope. FNPs in primary care clinics see patients with orthopedic complaints, and have completed instruction on medical management of those disorders, giving joint injections, splinting, etc... Could you clear this up for me a bit? Is this because it is a Surgical practice?
    Its all going to depend on your risk tolerance. If you were in New Mexico for example where the BON interprets the roles quite liberally and no collaboration agreement is required then you would probably be fine. On the other hand if you choose to practice where the BON interprets the role very tightly then you are one complaint away from losing your job. If you look at what the BON says:
    Determining scope of practice includes:

    • Advanced practice education in a role and specialty
    • Legal implications (e.g. compliance with the Nursing Practice Act and Board Rules)
    • Scope of practice statements as published by national professional specialty and advanced practice nursing organizations

    You can read it any way you choose. One way is as you stated that FNPs in primary care see orthopedic complaints. The other way is that specialty practice in orthopedics is outside the scope of someone trained in primary care. I'm sure that there are FNPs practicing in Texas hospitals. I am also sure that the BON would take a dim view of it when the found out.

    We are going through this currently here. The hospital has given FNPs that work in critical care more than 50% of the time 1 year to get their ACNP. The suspicion is that this will move to all inpatient positions over the next few years. The state BON has refused to rule on scope issues saying its up to the individual nurse to make sure they are in compliance. On the other hand the state BOM has to sign off on all collaboration agreements. Under the current rules they would probably find that orthopedics is not a primary care specialty and an orthopod could not collaborate with an FNP.

    Like I said you can try to stretch an FNP to fit a situation, it just depends on your risk tolerance.
    aprnKate likes this.
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    The following were taken from the 2008 Consensus APRN model.
    The link is provided on the Texas BON website.

    I think you're ok. Get the speciality certification once you have completed hours.
    Also document and keep any and all training in your specialty. All for CYA reasons.

    http://www.bon.texas.gov/practice/pdfs/aprnmodel.pdf
    http://www.bon.texas.gov/practice/gen-apn.html

    "Scope of practice of theprimary care or acute care CNP is
    not setting specific but is based on patient care needs. Programs may
    prepare individuals across both the primary care and acute care CNP competencies."


    "Preparation in a specialty area of practice is optional, but if included must build on the APRNrole/population-focused competencies. Specialty practice represents a much more focusedarea of preparation and practice than does the APRN role/population focus level. Specialtypractice may focus on specific patient populations beyond those identified or health care
    needs such as oncology, palliative care, substance abuse, or nephrology."


    "State licensing boards will not
    regulate the APRN at the level of specialties in this APRN Regulatory Model."
  3. 0
    Thanks so much questions answered
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    This is and interesting conversation. I've been working in the orthopedic nursing and first assisting role for 6+ years. Recently got my ANP certification. Before I did everything a PA would do in the hospital setting as an RN (rounding, admitting, consults, ED closed reductions, splinting, first assisting, suturing, you name it, accept seeing patients in the office). Remember your also a RN. All you need to do when writing orders is just like you did as a nurse. Just sign it as verbal order Dr. X and then your name and title. PA's do this too. If your ANP, FNP, GNP, just sign as a verbal order and the physician will co-sign or medical records will have him sign later. Also, for FNP and ANP in the clinic, same thing if unsure just have your MD cosign all your charts. This will allow higher billing and a better salary for you, plus liability protection. Nothing to worry about. I would encourage getting certified in all areas you work anyway. I do pretty much anything in surgery as long as the physician allows it and my licenses allow this. The only thing I don't do is make the initial incision. I assist and help the surgery, but I will not do the surgery for him or her. That's the difference. In surgical first assisting it's important understand that the surgeon is the "captain". i.e. if he ask you to drill something and while your drilling he say "stop", you STOP. Let him/her instruct you doing whatever he ask of you in the procedure. Don't ever assume command yourself. Always respect what he instructs and tells you. In this way the surgeon is the one who assumes the liability. We recently had a CST,CSFA make the initial incision before the surgeon entered the room and this became a huge deal and that person will lose privileges at that facility and the facility can and may report that person to the board. Just remember the surgeon leads the surgery period.

    Jeremy G, MSN, ANP-BC, RN, ONC, CSFA, LSA
  5. 1
    Quote from Jeremy G
    This is and interesting conversation. I've been working in the orthopedic nursing and first assisting role for 6+ years. Recently got my ANP certification. Before I did everything a PA would do in the hospital setting as an RN (rounding, admitting, consults, ED closed reductions, splinting, first assisting, suturing, you name it, accept seeing patients in the office). Remember your also a RN. All you need to do when writing orders is just like you did as a nurse. Just sign it as verbal order Dr. X and then your name and title. PA's do this too. If your ANP, FNP, GNP, just sign as a verbal order and the physician will co-sign or medical records will have him sign later. Also, for FNP and ANP in the clinic, same thing if unsure just have your MD cosign all your charts. This will allow higher billing and a better salary for you, plus liability protection. Nothing to worry about. I would encourage getting certified in all areas you work anyway. I do pretty much anything in surgery as long as the physician allows it and my licenses allow this. The only thing I don't do is make the initial incision. I assist and help the surgery, but I will not do the surgery for him or her. That's the difference. In surgical first assisting it's important understand that the surgeon is the "captain". i.e. if he ask you to drill something and while your drilling he say "stop", you STOP. Let him/her instruct you doing whatever he ask of you in the procedure. Don't ever assume command yourself. Always respect what he instructs and tells you. In this way the surgeon is the one who assumes the liability. We recently had a CST,CSFA make the initial incision before the surgeon entered the room and this became a huge deal and that person will lose privileges at that facility and the facility can and may report that person to the board. Just remember the surgeon leads the surgery period.

    Jeremy G, MSN, ANP-BC, RN, ONC, CSFA, LSA
    I'm going to let the NPs comment on whether you are within your scope of practice as an RN rounding, admitting, consults, ED closed reductions etc. I can't imagine you are in any state or hospital I've worked in.

    As for billing, for gods sake please take a billing class before you give advice. Having the physician co sign the chart does not allow you to bill at a higher level. I won't comment on the rest but it sounds as out of bounds as writing consults as an RN.
    aprnKate likes this.
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    I was told in my FNP program specifically that that we are not allowed to first assist unless we have a RNFA certificate. Back then there are FNPs who can work in acute care settings and there still some that do like in the ED fast track. However, they are trying to make a distinction between ACNP and FNPs. I would not even risk doing procedures like that. Only minor procedures in the office like abscess drainage or joint injections/aspirations are fine.
  7. 0
    It is my understanding that the Texas BON is intentionally vague in their delineation of scope of practice as it relates to ACNP versus FNP. Many hospitals are now setting hard boundaries, but that is up to the institution. One could argue that an RN with 3 years of inpatient ortho experience is well under way to care for ortho patients in an acute care clinic setting as an FNP. As long as you are properly trained to perform the tasks to which you are delegated, you should be operating within your personal scope of practice.
  8. 1
    Quote from TX RN
    The following were taken from the 2008 Consensus APRN model.
    The link is provided on the Texas BON website.

    "Scope of practice of theprimary care or acute care CNP is
    not setting specific but is based on patient care needs. Programs may
    prepare individuals across both the primary care and acute care CNP competencies."
    The point is that FNPs are trained and educated in PRIMARY CARE, not in acute care. You're right, the setting of clinic v hospital is not the important factor in the consensus model. The important factor is that hospital patients undergoing surgery are not primary care patients; they are clearly and obviously acute care patients.

    JeremyG - in your scenario, what's the point of becoming a CRNP if you "verbal order" everything and bill under the physician's NPI?
    aprnKate likes this.


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