Can NPs practice with surgeons?

DaisyRN, ACNP · Apr 17, 2007

I was under the impression that they could only see acute and critically ill patients. The local program here is a ANP/ACNP program. The instructors are stating that outpatient work is outside the scope of practice of an ACNP. There seems to be some overlap in urgent care. If you look at the CCRN ACNP certification it does not mention outpatient treatment of chronic disease:
"The ACNP practices in any setting in which patient care requirements include complex monitoring and therapies, high-intensity nursing intervention, or continuous nursing vigilance within the range of high-acuity care. While most ACNPs practice in acute care and hospital based settings including sub-acute care, emergency care, and intensive care settings, the continuum of acute care services spans the geographic settings of home, ambulatory care, urgent care, and rehabilitative care."
I guess you could interpret amublatory care as outpatient and the joint comission lists physician offices as one of the many types of amublatory care office. I would have a problem describing most IM or even specialty care as high acuity care.
The ANCC is much more open on thier interpretation:
"The Acute Care Nurse Practitioner (ACNP) is a registered nurse prepared in a graduate level acute care nurse practitioner program to provide and manage health care of acutely ill, critically or chronically ill adult patients in a wide range of settings."
So I guess it depends on which certification you get not your training which seems odd.
Also I will point you at this article:
http://www.medscape.com/viewarticle/506277_7
In particular this response:
Should an NP who is educationally prepared as an acute care NP work in an adult primary care setting?
The answer is no. The acute care NP program prepares graduates for a specialty focus in acute, episodic, and critical conditions that are primarily managed in a hospital-based setting. The program of study does not contain adequate clinical and didactic content to support the ACNP for a broader role in outpatient primary care diagnosis, treatment, and follow-up. Diagnosis and outpatient management of stable and unstable chronic illness, as well as directing health maintenance of a wide range of conditions, is a required competency for practice in the primary care role.
Additionally, professional licensure and certification will reflect validation that the provider has met criteria for practice in a focused, rather than broad, scope of practice. Finally, the environment of primary care is not congruent with the acute care secondary or tertiary care training focus. A lack of congruence between the practice environment and level of expertise results in a decreased level of safety for the patient and increased risk of liability for the NP.
I think this would leave open wether you could work in specialty practice. Internal medicine is usually regarded as primary care. If you look at the article that Sari posted on PNP there seems to be some agreement to divide APN along a primary care or acute care practice line. If you could see internal medicine why couldn't you see adult FP patients? They are essentially the same population.
David Carpenter, PA-C
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Let me also add... what do you think is really fair to your patients? If you can HONESTLY sit back and think to yourself, "I've had enough training in the managment of chronic disease in an outpatient setting, including lectures on pathology, differential diagnosis, clinical experience, and long term pharmacologic interventions of those chronic outpatient conditions in my ACNP program to feel comfortable treating my mother." The go ahead, treat people, even though it may be outside of your scope. I think, in reality, MOST ACNPs would tell you that in their schooling they did not learn long term pharmacologic therapies, or how to manage chronic illnesses. I certainly would like to hear the TRUTH from some of the ACNPs on the board.

David and caldje,

I was not trying to be argumentative... I was simply stating what I have been taught in my ACNP program. I just completed an internal medicine rotation and I do believe that ACNPs are qualified for this due to the normally complex medical problems of the internal med patients (diabetes, cardiac, and pulm all at once) as opposed to the often described "less critical" FP patients.

I do understand that there is great overlap between the two populations, David. The only populations that I, legally, cannot see include pregnant women and children. This also supports why a general FP clinic would be inappropriate... perhaps if there were adult only FP clinics, an ACNP could be utilized in that manner. In my IM rotation, I have been learning to manage chronic diabetic patients, performing well-woman exams, interpreting xrays/ekgs/labs in the office, as well as writing admission orders for patients when necessary.

Personally, I chose the ACNP program because I DO want the inpatient focus... but I know several of my peers are going to be in the outpatient settings, i.e. pain management, cardiology, and renal.

Also, because of the inconsistencies in teaching/guidelines/standards/scope, I purchased the AACN book "Scope and Standards of Practice for the Acute Care Nurse Practitioner" (2006). I'll include snippets from the book in a different message. See below.

DaisyRN, ACNP · Apr 17, 2007

The AACN "Scope of Practice for The Acute Care Nurse Practitioner" (2006) book states, "The purpose of the ACNP is to provide advanced nursing care across the continuum of healthcare services to meet the specialized physiological and psychological needs of patients with acute, critical, and complex chronic health conditions [PERHAPS THIS IS WHAT QUALIFIES IM]. This care is continuous and comprehensive and may be provided in a variety of inpatient OR outpatient settings" (p. 9). The populations includes acutely and critically ill patients experiencing episodic illness, stable and progressive chronic illness, acute exacerbations of chronic illness, or terminal illness (p. 10).

Throughout the book it uses the phrase, "acute, critical, and chronically-ill patients"... in other areas in the book it uses a similar phrase of "acute, critical, and complex chronically ill patients"...

On page 12, it addresses the practice environment...

"The ACNP practices in any inpatient or outpatient setting in which patient care requirements include complex monitoring and therapies, high intensity intervention, or continuous vigilance within the range of high acuity care. While most ACNPs practice in acute care and hospital-based settings (including sub-acute care, emergency care, and intesive care settings), the continuum of acute care services spans the geographic settings of home, ambulatory care, urgent care, rehab care, and palliative care. The practice environment may also extend into virtual locations such as eICU and Telemedicine." (I think you provided a lot of this same info, David.)

Further in the book it provides examples of ACNPs utilization, i.e. Cardiothoracic ICU, Bone Marrow Transplant services, Diagnostic/Interventional Services, Heart failure services (including outpatient clinic), and Orthopedics.

Generally speaking, from what I saw in my IM rotation and from what other healthcare folks have told me, patients of an IM clinic are generally more complex with overlapping illnesses that require more intense management than those visiting FP clinics. This is not to downgrade the patients that do follow FP clinics, because I know that many of these patients are also complex. Comparatively though, IM gives more complex patients than FP. Also, in terms of the "complex monitoring and therapies, high intensity intervention, or continuous vigilance," I know that at the IM office I was doing my preceptorship in, most patients were seen on a VERY regular basis... my NP preceptor provided the care for most of the office's diabetic patients and this involved use of CGMS (continous glucose monitoring), regular follow up, and vigilant care of their diabetes. These patients were "regulars" if you will.. but they weren't there for routine follow-ups. Their visits involved difficult alterations in their plans of care at nearly each visit.

Perhaps another difference b/w the IM and FP setting would be the emphasis placed on comorbidity and drug interaction... I'm not sure what FPs receive in their training, but I know that in the IM setting, I have had to pay SPECIAL attention to prescribing, etc. in terms of current conditions and medications because there are so many interactions among drugs/disease processes. I know that there is standardized care regardless of APN training, but what we have dealt with is VERY involved in terms of managing multiple conditions and the drugs for each. Some of my FP student friends have voiced the fact that they are not getting as much education regarding this type of management. That there education is more straight-forward for each disease process... and not focused so much on how to manage multiple problems at once.

Hope this helps... I feel like I'm not saying what I am thinking... I hope it makes sense. *lol*

DaisyRN, ACNP · Apr 17, 2007

Let me also add... what do you think is really fair to your patients? If you can HONESTLY sit back and think to yourself, "I've had enough training in the managment of chronic disease in an outpatient setting, including lectures on pathology, differential diagnosis, clinical experience, and long term pharmacologic interventions of those chronic outpatient conditions in my ACNP program to feel comfortable treating my mother." The go ahead, treat people, even though it may be outside of your scope. I think, in reality, MOST ACNPs would tell you that in their schooling they did not learn long term pharmacologic therapies, or how to manage chronic illnesses. I certainly would like to hear the TRUTH from some of the ACNPs on the board.

And caldje... I have/am receiving EXTENSIVE training in the "management of chronic disease... pathology, differential diagnosis, clinical experience, and long term pharmacologic interventions of those chronic outpatient conditions" and would be more than happy caring for ANY of my family members in this setting. Also, the text that we are utilizing for our studies is the Harrison's Internal Medicine book used in MEDICAL school. Our lectures are VERY involved and complex regarding the previously mentioned topics. I am not saying that I want to do outpatient, at all, but I feel that if an ACNP is qualified (much like i am being trained), then it would be appropriate for him or her to do so.... that's all.

core0 · Apr 18, 2007

And caldje... I have/am receiving EXTENSIVE training in the "management of chronic disease... pathology, differential diagnosis, clinical experience, and long term pharmacologic interventions of those chronic outpatient conditions" and would be more than happy caring for ANY of my family members in this setting. Also, the text that we are utilizing for our studies is the Harrison's Internal Medicine book used in MEDICAL school. Our lectures are VERY involved and complex regarding the previously mentioned topics. I am not saying that I want to do outpatient, at all, but I feel that if an ACNP is qualified (much like i am being trained), then it would be appropriate for him or her to do so.... that's all.

It sounds like you are getting an excellent education. I wonder if all ACNP students are getting a similar education? If all students are getting a similar education and experience this shouldn't be a problem. This is not my understanding of the general education experience (small N as the ACNP is not well developed here). Most of the ACNP's around here are trained as hospitalists or critical care.

It also sounds like your IM practice is not the norm. I can only speak to my referral base, but CGMS and type I DM management is generally done in an endocrinology office here not IM. For the most part IM acts like an FP office without the peds. The part that I am not sure that you have training in is the essence of the ANP and FNP, what we would refer to is well care. This is anticipatory guideance and preventive health maintenance. While in general IM might see more complex patients than FP it really depends on the practice. I see FP practices that have patients as or more complex than IM practices including very advance psych management.

I did my IM rotation in a solo practice that did endocrinology and IM. I saw the difference between the two. I have looked at the same scope of practice book. The difference is that ACNP only sees patients that are ill. Is it within your scope to see a patient that is not ill? For example can you see someone for a physical and provide appropriate anticipatory guideance? This is what FNP and ANP are extensively trained in.

David Carpenter, PA-C

caldje · Apr 18, 2007

here is what I just can't wrap my brain around... I have heard this from about half the NPs I have met, the other half agree with me. (as with david, this is still a small n).

IF, a FNP, ANP, PNP can practice in an inpatients setting or an ER, and an ACNP can practice in an outpatient setting like a general IM clinic... Then WHY, please explain, are they completely different schooling, completely different clinical requirements, and completely different certification exams. It just does not make sense to me and nobody has really given me a sensinble answer for it. And please trust me, I am more than willing to change my mind about how I feel about this.

DaisyRN, ACNP · Apr 18, 2007

here is what I just can't wrap my brain around... I have heard this from about half the NPs I have met, the other half agree with me. (as with david, this is still a small n).
IF, a FNP, ANP, PNP can practice in an inpatients setting or an ER, and an ACNP can practice in an outpatient setting like a general IM clinic... Then WHY, please explain, are they completely different schooling, completely different clinical requirements, and completely different certification exams. It just does not make sense to me and nobody has really given me a sensinble answer for it. And please trust me, I am more than willing to change my mind about how I feel about this.

You know caldje, that is the largest problem with multiple specialty APNs. I know that last year when I met with the President of the Texas BNE, she expressed concern regarding this very problem... she said that the state of Texas (with the support of others) is working towards standardizing APN education much like that of a PA program and then offering specialization post-master's. Something else to remember is that the regulating boards are working on standardizing competencies for each specialty and subsequent jobs. Maybe not "standardizing" so much as "ensuring" competencies.

I just read an article pertaining to this in the April 2007 Nurse Practitioner Journal entitled "Ensuring ACNP Competencies" or something like that... and so the states seem to be working on a solution, but we all know its not something that will be fixed overnight. Also, I think, much like you and David have indicated, there is a great deal of gray area in interpreting the scopes, etc. From a conference I visited last year, I was told that FNPs should not be making rounds in the hospital because they are not trained in acute care. Same goes for the ACNP in the general medicine outpatient settings, if what ya'll were saying is correct.

Basically, I think it all boils down to how you interpret the standards/guidelines. Unfortunately, those that have misinterpreted them, will be shooting themselves in the feet when standardization of competencies and education comes around. And when they are required to exhibit mastery of competency and are unable to do so.

It kinda reminds me of reading the Bible... depending on the preacher and the denomination of his or her congregation, its open to interpretation that is fitting to the one reading it.

DaisyRN, ACNP · Apr 18, 2007

I've attached a copy of that article, in case you are interested. It's not very long, but provides some helpful information.

EnsuringClinicalCompetency.pdf

core0 · Apr 18, 2007

You know caldje, that is the largest problem with multiple specialty APNs. I know that last year when I met with the President of the Texas BNE, she expressed concern regarding this very problem... she said that the state of Texas (with the support of others) is working towards standardizing APN education much like that of a PA program and then offering specialization post-master's. Something else to remember is that the regulating boards are working on standardizing competencies for each specialty and subsequent jobs. Maybe not "standardizing" so much as "ensuring" competencies.
I just read an article pertaining to this in the April 2007 Nurse Practitioner Journal entitled "Ensuring ACNP Competencies" or something like that... and so the states seem to be working on a solution, but we all know its not something that will be fixed overnight. Also, I think, much like you and David have indicated, there is a great deal of gray area in interpreting the scopes, etc. From a conference I visited last year, I was told that FNPs should not be making rounds in the hospital because they are not trained in acute care. Same goes for the ACNP in the general medicine outpatient settings, if what ya'll were saying is correct.
Basically, I think it all boils down to how you interpret the standards/guidelines. Unfortunately, those that have misinterpreted them, will be shooting themselves in the feet when standardization of competencies and education comes around. And when they are required to exhibit mastery of competency and are unable to do so.
It kinda reminds me of reading the Bible... depending on the preacher and the denomination of his or her congregation, its open to interpretation that is fitting to the one reading it.

I think it is a natural tension between those who work and those who teach. In the NP world the emphasis has been on accessability of programs. Wether this emphasis is good or bad I will leave to you. NP's may not necessarily take programs because that is the field of nursing is what they like or are interested in but because of accesability. Initially there was no ACNP and FNP's filled that role (usually NP's with strong ICU or cardiology backgrounds). With the advent of the ACNP there are still NP's that want that role but are lacking in local programs.

On the same side there are FNP's that are graduating and finding primary care positions pay less than inpatient nursing salaries. They are looking for positions that pay better and they are finding these are generally inpatient and specialty medicine positions. So they are taking positions that they may not be clinically or didactically trained for. While I have no problem with this in a general way, the Nursing leadership and the BON's are very clear that as independently licensed providers, NP's are outside of their scope if they are working outside of their clinical and didactic training. The certifying organisations have expanded the scope of practice (take a look at the original ACNP vs the current) without showing that the NP's have additional training to cover these areas. You have a corollary where ACNP's are finding jobs with partial outpatient duties and trying for these jobs.

Wether anyone wants to adimit it there are also monetary considerations here. If you have to get extra post grad certifications to work that means more $$$$ to the programs.

Finally you are attempting to impose a nursing model on a medical system. Outside of pure primary care all of these NP jobs are working in a medical practice. In specialty medicine you are practicing in a collaborative role and usually employed by the practice or hospital. The problem is that the medical model does not follow the nursing model. Medical practices may involove inpatient, outpatient or both. They may involve primary care and critical care. They may involve acute or chronic disease. They may practice accross all age groups. This does not fit into the current NP model. Attempting to move into these areas frequently crosses scope of practice boundaries.

The hospital credentialling comittees are starting to see the liability here and the SBON's seem to be uncomfortable with this. Ultimately the DNP will probably fix most of these problems by allowing the student to tailor their didactic and clinical experience to the position. The problem will come if they want to change positions.

David Carpenter, PA-C

caldje · Apr 18, 2007

You know caldje, that is the largest problem with multiple specialty APNs. I know that last year when I met with the President of the Texas BNE, she expressed concern regarding this very problem... she said that the state of Texas (with the support of others) is working towards standardizing APN education much like that of a PA program and then offering specialization post-master's. Something else to remember is that the regulating boards are working on standardizing competencies for each specialty and subsequent jobs. Maybe not "standardizing" so much as "ensuring" competencies.
I just read an article pertaining to this in the April 2007 Nurse Practitioner Journal entitled "Ensuring ACNP Competencies" or something like that... and so the states seem to be working on a solution, but we all know its not something that will be fixed overnight. Also, I think, much like you and David have indicated, there is a great deal of gray area in interpreting the scopes, etc. From a conference I visited last year, I was told that FNPs should not be making rounds in the hospital because they are not trained in acute care. Same goes for the ACNP in the general medicine outpatient settings, if what ya'll were saying is correct.
Basically, I think it all boils down to how you interpret the standards/guidelines. Unfortunately, those that have misinterpreted them, will be shooting themselves in the feet when standardization of competencies and education comes around. And when they are required to exhibit mastery of competency and are unable to do so.
It kinda reminds me of reading the Bible... depending on the preacher and the denomination of his or her congregation, its open to interpretation that is fitting to the one reading it.

So we agree that there is a problem and a lot of gray area. In such a case, I dont understand how you could feel that it is alright for ACNPs to work in an outpatient setting. I mean, not only is it risky medicolegally, but it is also not fair to patients to not have a provider who was trained appropriately for the position they are filling. At least until the gray area is defined or the education is standardized.

jer_sd · Apr 18, 2007

So we agree that there is a problem and a lot of gray area. In such a case, I dont understand how you could feel that it is alright for ACNPs to work in an outpatient setting. I mean, not only is it risky medicolegally, but it is also not fair to patients to not have a provider who was trained appropriately for the position they are filling. At least until the gray area is defined or the education is standardized.

Ok so how does PA-C school allow graduates to work in any area of medicine when they do not have didactic and clinicl time in specilty practices such as neurology, nephrology or other areas. PAs require time post graduate to learn specilty areas that they did not have dedicated lecture and clinical time in. True PA educaiton does give a wider base than even FNP but even with the extra didactic and clinical time it does not allow for exposure to all aspects of medicine.

Proffesional education is a foundation for practice, clinicians are then rtesponsible to ensure that the care they provide to patients is reasonable and safe and if they can not provide they must refer to the appropriate provider. Post graduate education and experience can suppliment proffesional education but it does not serve to replace it. A PNP should not care for adults, an ANP should not care for children. If an ACNP program provided didactic and clinical time in primary care settings on management of chronic side of acute issues then it migh tbe safe, that woudl depend not only on the school but also the student.

To complicate matters all 50 states have different rules, regulations and statements for practice, some can only practice within narrow guidlines, some can have wide scope.

I am the first to notice the deficiencies of NP eduction, I am with David that the DNP will be a step in the correct direction if it provides a solid foundation of basic care for NPs, then a focus can be established. Even with problems in education NPs continue to provide excellent care for patients and the intraproffesional squable between MDs, PAs, NPs ect does not make patient care better when we all work on teh same team in the real world.

Jeremy

core0 · Apr 18, 2007

ok so how does pa-c school allow graduates to work in any area of medicine when they do not have didactic and clinicl time in specilty practices such as neurology, nephrology or other areas. pas require time post graduate to learn specilty areas that they did not have dedicated lecture and clinical time in. true pa educaiton does give a wider base than even fnp but even with the extra didactic and clinical time it does not allow for exposure to all aspects of medicine.
it does not cover all im specialties but it does give a solid base in internal medicine. you also cover all these areas in a fair amount of detail in the didcactic part. the other part is that pa's are dependent practitioners so our scope is defined by what the physician is allowed to do and what the physician allows the pa to do.
proffesional education is a foundation for practice, clinicians are then rtesponsible to ensure that the care they provide to patients is reasonable and safe and if they can not provide they must refer to the appropriate provider. post graduate education and experience can suppliment proffesional education but it does not serve to replace it. a pnp should not care for adults, an anp should not care for children. if an acnp program provided didactic and clinical time in primary care settings on management of chronic side of acute issues then it migh tbe safe, that woudl depend not only on the school but also the student.
the problem i have is where is this time coming from? if a program is providing that the student do additional rotations beyond the hours required for acnp in critical care medicine then fine. but if they are taking the hours provided for critical care and using some of these for outpatient medicine (and i am speaking of outpatient specialty care/primary care) then they are shortchanging the student and will not give the students the skill set they need to do the inpatient job. if a acnp does all their clinicals in a im office with no inpatient experience then they can still work as an acnp where the expectation will be to handle critically ill patients without any of the experiece doing this.
this is the biggest criticism i have of the np educational model. look at any other provider (crna, pa, cnmw, or physician). there are extensive guidelines over what the provider must be exposed to during their clinical rotations and what material must be covered in the didactic phase. if similar guidelines exist for np education (outside of the nnp) i have not been able to find them. this results in a wide variety of educational experiences with little common ground.
to complicate matters all 50 states have different rules, regulations and statements for practice, some can only practice within narrow guidlines, some can have wide scope.
i am the first to notice the deficiencies of np eduction, i am with david that the dnp will be a step in the correct direction if it provides a solid foundation of basic care for nps, then a focus can be established. even with problems in education nps continue to provide excellent care for patients and the intraproffesional squable between mds, pas, nps ect does not make patient care better when we all work on teh same team in the real world.
jeremy

the problem i have with the dnp is that i am not sure how they handle mobility. if a dnp does endocrinology and then wants to do cardiology what is the mechanism here? it is really not an interprofessional squabble as an intraprofessional squabble. in some ways i agree with the sbon theory that there should only be an np wtth further training afterwards. you get your np and then differntiate into whatever field. the problem with all this is not with the individual but with organizations. organizations like categories. pa's fit into whatever category their sponsoring physician is in. np's have their own categories and as you have seen here there is a divergent opinion on who can do what. this will probably get worse with the npi when insurance companies start seeing who is actually seeing the patients.

david carpenter, pa-c

caldje · Apr 19, 2007

Ok so how does PA-C school allow graduates to work in any area of medicine when they do not have didactic and clinicl time in specilty practices such as neurology, nephrology or other areas. PAs require time post graduate to learn specilty areas that they did not have dedicated lecture and clinical time in. True PA educaiton does give a wider base than even FNP but even with the extra didactic and clinical time it does not allow for exposure to all aspects of medicine.
Jeremy

What you describe here, neurology, neprhology, etc. are all medical SUBspecialties. A branch off of the internal medicine specialty. PAs do recieve plenty of didactic and clinical training in both outpatient and inpatient internal medicine which covers the SUBspecialty topics, just not like an MD fellowship would (of course). The same goes for surgical SUBspecialties.. There is required didactic and clinical training in surgery, both intraop and periop in PA programs. In addition, ALL PA programs have these requirements, there is not a PA graduating that hasnt met those requirements. Now, they could still be an AWEFUL PA, but that is a whole nother story.

I also disagree that the "professional" squabble doesn't benefit patients. I think any critical analysis of a persons/profession's background can be VERY beneficial for all parties involved. It is a very hard task to look at your own profession and self too critically, you NEED other people to point these things out or you will never see them. Where it is useless is when it gets backhanded and dirty. I think David does a very good job (better than me) of keeping things very professional and objective. In that kind of atmosphere only good things can come out of it. That is why we are here, to learn, and some of us may be the future policy makers of our profession... don't you think we need input from everyone?