Can NPs practice with surgeons?

jer_sd · Apr 10, 2007

NPs can and do work with surgeons.

Often they provide:

preoperative assesment- history physical, ording correct labs, medications, patient education on surgery ect..

postoperative care such as rounding in the hospital or seeing patient in clinic.

With additional training they can function as a first assistant and be involved in the operation.

More PAs work in surgery but a NP can do this as well. The main weakness in our training for this role is lack of surgical experience, I would strongly recomend attending a RNFA course rather than just learning on the job.

Jeremy

core0 · Apr 10, 2007

NPs can and do work with surgeons.
Often they provide:
preoperative assesment- history physical, ording correct labs, medications, patient education on surgery ect..
postoperative care such as rounding in the hospital or seeing patient in clinic.
With additional training they can function as a first assistant and be involved in the operation.
More PAs work in surgery but a NP can do this as well. The main weakness in our training for this role is lack of surgical experience, I would strongly recomend attending a RNFA course rather than just learning on the job.
Jeremy

I would be very careful with RNFA courses. A lot of them are a lot of money for not much value. The other point is that you still have to get your hours in the OR before you can get your RNFA. You might look at the RNFA/FNP program at UAB.

I have always wondered why there is not a Surgical NP. Instead of cludging something together like RNFA/NP where you are not specifically taught inpatient or outpatient surgical management why not design an NP program from the ground up to do this.

David Carpenter, PA-C

jer_sd · Apr 10, 2007

You will need 120-200 hours of clinical practice to graduate from a RNFA program and be a RNFA. Often NPs can enter these programs without OR experience.

Inorder to be certified as a CRNFA you will need 2000 hours experience and your CNOR certification.

Having been through NP programs and one RNFA program the RNFA program does compiment NP education. Some facilities will require proof of completing a RNFA program prior to providing you surgical assistant privliges. The program to look at are listed here: http://www.cc-institute.org/cert_crnf_prep_rnfa.aspx

Tuition varies a lot based on the program here are 4 examples

UCLA- $1450

Southwest Florida College $1695

Elite School of Surgical First Assisting $5995

Northeastern University, School of Professional and Continuing Studies, Boston $3000

Under 2k is not bad for the potential doors it can open for your future. Plus my RNFA prgram was fun to learn. I did NIFA which was more expensive than UCLA (did not know better)

I would love to see a surgical NP program but it would fit great into a ACNP focus like the program mentioned above. Stand alone it would be a limited job market. What I think woudl be even better is a NP residency in surgery similar to what PAs can take.

Jeremy

Columnist · Apr 10, 2007

I have always wondered why there is not a Surgical NP. Instead of cludging something together like RNFA/NP where you are not specifically taught inpatient or outpatient surgical management why not design an NP program from the ground up to do this.

I like this idea. I like nursing but also would like to be involved in surgery.

If I have the details correct, University of New Mexico's ACNP program offers three specializations, one of which is surgical assisting. That's the closest nursing equivalent I know of to a PA. Note: I can't find this info on UNM's website; I heard of it via a current ACNP student.

Elizabeth

core0 · Apr 11, 2007

You will need 120-200 hours of clinical practice to graduate from a RNFA program and be a RNFA. Often NPs can enter these programs without OR experience.
Inorder to be certified as a CRNFA you will need 2000 hours experience and your CNOR certification.
Having been through NP programs and one RNFA program the RNFA program does compiment NP education. Some facilities will require proof of completing a RNFA program prior to providing you surgical assistant privliges. The program to look at are listed here: http://www.cc-institute.org/cert_crnf_prep_rnfa.aspx
Tuition varies a lot based on the program here are 4 examples
UCLA- $1450
Southwest Florida College $1695
Elite School of Surgical First Assisting $5995
Northeastern University, School of Professional and Continuing Studies, Boston $3000
Under 2k is not bad for the potential doors it can open for your future. Plus my RNFA prgram was fun to learn. I did NIFA which was more expensive than UCLA (did not know better)
I would love to see a surgical NP program but it would fit great into a ACNP focus like the program mentioned above. Stand alone it would be a limited job market. What I think woudl be even better is a NP residency in surgery similar to what PAs can take.
Jeremy

I thought the RNFA was a title and the CRNFA was the certification. Can you call yourself an RNFA without being certified? Will hospitals accept the class alone without being eligible for the certification?

I have looked at the NIFA course in particular and have a hard time seeing how you can train surgical assisting for in 54 hours. I was a CST before PA school and that training which does not really cover assisting was 500 hours of didactic and three months of scrubbing. Most OR nursing courses are similar.

Also the NIFA if I am reading this correctly still requires the same periop experience:

"The RNFA candidate must have a minimum of two years of recent perioperative nursing experience. This experience must include demonstrated competency in the scrubbing, circulating or first assisting roles of the intraoperative nursing dimension."

So you still have the circular problem of needing experience to get experience.

David Carpenter, PA-C

core0 · Apr 11, 2007

I like this idea. I like nursing but also would like to be involved in surgery.
If I have the details correct, University of New Mexico's ACNP program offers three specializations, one of which is surgical assisting. That's the closest nursing equivalent I know of to a PA. Note: I can't find this info on UNM's website; I heard of it via a current ACNP student.
Elizabeth

The problem with this is that it does not meet the market needs. I will be the first to admit that most surgeons do not understand the use of NPP's. Also an academic setting is different from a community setting. That being said the way that NPP's pay for themselves is different from other settings. There are three settings that a NPP works in. Pre-op, intra-op and post-op. Of these only the Pre-op and intra-op portions generate revenues. The post-op portions are included in the procedure fee.

An NPP needs to be able to generate money in both the clinic and hospital. An ACNP cannot see patients in an outpatient setting (depending on which particular certification being gained) and does not get training in the medical management of outpatient conditions.

Probably the best utilizers of NPP's are Orthopods. In their model the Patient is usually seen and evaluated initially by the NPP and any imaging is done. Then a treatment plan that may include rehab, injections etc is formulated. All of this is billable and brings in substantial income. At some point a decision for surgery is made. The patient has surgery, the NPP gets the assist fee. The NPP usually does the follow up work. The direct revenue is considerable and usually is double the NPP's salary. The only study that I am aware of shows that for PA's the downstream revenue is about 60-90% of this. The downstream revenue consists of the surgeon doing procedures for which there is no assist fee while the NPP see's followups and the ability of the physician to see more new consults while the NPP sees follow ups.

So for an NPP to work with a surgeon they need to be able to do pre operative testing and therapy, intraoperative assistant, post op management and follow up care. If you look at the competencies you are talking about a ANP, RNFA and ACNP. An ANP program which has inpatient and outpatient components might work. Also since most surgeons will see patients under the age of 18 you have to have pediatric competencies.

David Carpenter, PA-C

jer_sd · Apr 11, 2007

David,

When a RN graduates from a RNFA training program they can be called a RNFA, after one year work and passing the board exam the nurse can then sign CRNFA,

One hospital I work at requires NPs to have proof of completing a RNFA program, and CNOR certification for first assisting privliges, the other requires NP licensure. No facility requires CRNFA in my area, and to bill medicare a NP requires no additional training.

Advacned practice nurses generally do not need the two years OR experience and CNOR certification to enroll in RNFA programs. If you look further down on the NIFA page it has this to say:

* AD and Diploma nurses do not need a BSN to enroll or complete program. Certified advanced practice nurses do not need CNOR nor two years OR experience to complete this program.

When I completed the NIFA program it was much longer than 54 hours. The 54 hours is lab experience, then there is a significant ammount of didactic work prior to that (I believe it was between 100-200 hours but I would have to pull up the documents) this didactic work was done by distance learning, then skills lab then clinical. (my clinical rotation was close to 400 hours since it only counted time with patients so it added lots of hours to the total) Total of 9 semester hours of credit for the program.

I did have surgical experience so learning instuments and basics were easy for me. This progam was also a great prep for CNOR certification.

Jeremy

I thought the RNFA was a title and the CRNFA was the certification. Can you call yourself an RNFA without being certified? Will hospitals accept the class alone without being eligible for the certification?
I have looked at the NIFA course in particular and have a hard time seeing how you can train surgical assisting for in 54 hours. I was a CST before PA school and that training which does not really cover assisting was 500 hours of didactic and three months of scrubbing. Most OR nursing courses are similar.
Also the NIFA if I am reading this correctly still requires the same periop experience:
"The RNFA candidate must have a minimum of two years of recent perioperative nursing experience. This experience must include demonstrated competency in the scrubbing, circulating or first assisting roles of the intraoperative nursing dimension."
So you still have the circular problem of needing experience to get experience.
David Carpenter, PA-C

DaisyRN, ACNP · Apr 12, 2007

An NPP needs to be able to generate money in both the clinic and hospital. An ACNP cannot see patients in an outpatient setting (depending on which particular certification being gained) and does not get training in the medical management of outpatient conditions.
David Carpenter, PA-C

Hey David,

Just FYI: the ACNP *can* do the outpatient setting in an Internal Medicine or specialist office, i.e. pulm/cardi/GI, etc. Just no Family Medicine... and that may have been what you meant when you said,

"depending on which particular certification." Just wanted to clarify for others...

I thought the same thing until I got into the program... and I just finished my Internal Medicine rotation... :)

Columnist · Apr 12, 2007

Hey David,
Just FYI: the ACNP *can* do the outpatient setting in an Internal Medicine or specialist office, i.e. pulm/cardi/GI, etc. Just no Family Medicine... and that may have been what you meant when you said,
"depending on which particular certification." Just wanted to clarify for others...
I thought the same thing until I got into the program... and I just finished my Internal Medicine rotation... :)

Thank you for clarifying this. I did believe ACNPs could see pts in the outpatient setting, but I hadn't had time to look up the particulars.

Elizabeth

core0 · Apr 13, 2007

Hey David,
Just FYI: the ACNP *can* do the outpatient setting in an Internal Medicine or specialist office, i.e. pulm/cardi/GI, etc. Just no Family Medicine... and that may have been what you meant when you said,
"depending on which particular certification." Just wanted to clarify for others...
I thought the same thing until I got into the program... and I just finished my Internal Medicine rotation... :)

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

caldje · Apr 13, 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.