ER/ED Nurse Practitioner

[danceluver]

Hello!

I am curious as to the job responsibilities of a Nurse Practitioner who works in the Emergency Department. What exactly are they able to do (aside if there are no residents in this hospital)? Is it more the fastrack stuff? Is it challenging work?

In an FNP program, are you able to request to do such a clinical rotation, or even in a PNP program?

How much ED experience do most practices/hospitals like to see (RN) nurses have before they delve into the role of NP in this setting? Are new grads hired in one with ED/ER exp?

Do FNPs get hired in a Peds ED or do they prefer PNPs?

What about Urgent Care Centers--same as Fast Track job responsibilities?

What is the pay like in these settings as a new grad? Or someone with a few years experience?

Those of you who work in this field, do you find it challenging and enjoyable?

Thank you.

[PatMac10,RN, RN]

Many states in fact DO NOT! A few states do this usually they have restrictive practices as well. The states I practice in use FNPs extensively for solo ER coverage. You are it. There are also programs coming out such as West Virginia university emergency medicine program that you can do to document education. Accn also has a ENP certification oit that is portfolio based but another way for FNPs to document ER education and training.[/quote']

I agree. Many states, especially in the rural south (I'm in NC) don't restrict FNPs to primary care be yaw in many places here (whether it be clinics or EDs) FNPs/PAs are providing a lot, if not most of the care. I work on a CVICU (where we a lot of CABGs) and our CT surgeon utilizes an FNP as his extender. She pretty much manages the call for the patients after PO day 3. Of course the surgeon still reviews pt. updates and care decisions every so often. FNPs are the only APRNs, outside if CRNAs, that can see pt across the life span, therefore many states and areas similar to mine can't afford restrict their practice to solely primary care. We have some NP managed EDs in our smaller hospitals here in NC.

[nomadcrna, DNP, CRNA, NP]

No offense but please don't use the term "extender" pr midlevel. It is derogatory.

We are independent practitioners not someone's extender.

[RN-CEN TS]

My comments for the OP were meant for guidance on where to find the most accurate information regarding his question. I fully understand many ED's utilize FNP. However, in some states FNP's are practicing out of the scope of practice by seeing acute patients, as defined by their state's nurse practice act.

On another note, it seems as though it would be difficult to solely run an ED with NP's in any state where they could not prescribe schedule II medications. I know roughly half the states do not allow NP's to prescribe schedule II medications.

My post was not to say FNP can not, or are not suitable for the ED. I believe the contrary. Nurse Practice acts change with how the national certifications are changing and to meet the needs of the population of their state. I think it would be wise for the OP to refer to his/her board of nursing and nurse practice act for better understanding.

I currently am in enrolled in an Advanced Emergency Nurse Practitioner program. I chose this program because it is dual certification upon completion for Adult/Gero Acute Care NP and FNP. It is twice the amount of clinical hours but well worth the investment. If my states decides FNP should only work family clinic I am covered by the AGAC-NP certification. Not to mention employment opportunities abound with dual national certification. I would not want to risk going FNP for my dream job of an ENP-BC only for my state to say FNP can not practice in acute setting 5 years after I graduate.

The ENP-BC is by portfolio with two years of experience documented and a couple other qualifiers. Also, even if you become a FNP who is ENP-BC and your states nurse practice act states FNP can not practice in the ED, you are out of luck and better be happy with moving to a state where you can practice in an ED with an FNP. The ENP-BC is not currently held at the same credentialing level as AGACNP, FNP, etc. It is mainly to distinguish those who work in that specialty.

[nomadcrna, DNP, CRNA, NP]

1. I would suggest you check your information before posting in an NP forum especially as you are nor even an NP yet.

2. Pe the DEA only 9 states do not allow NPs to prescribe schedule 2. That is a long way from the 25 you state.

3. The "some" states in your last ost is also quite a bit different than " many" states you stated before. Some states would probably be more accurate as a few states.

4. Just as you have independent practice states as compared to restrictive states, you will have some that will try to keep FNPs in the clinic. You could even go so far to say some states may not allow you to see kids with acute issues as you don't have peds ACNP only adult. Oh my! How ridiculous, really. Technically, you cannot see a child with an acute care issue.

5. Come to Montana, Alaska, Idaho, Washington, Arizona, Wyoming to name just a few. See how many ERs have Nps as the sole provider.

6. The states want documentation of education and training . The ENP as well as the other post graduate programs do this.

7. If you look at the states that do not allow FNPs to practice n the ER, they are also the most restrictive in practice issues. Why would you want to work there any way?

After you finish school and start to practice it will make more sense. The rules are political and make no sense. How many acute issues do you see in primary care on a daily basis? Many, every day.

[allennp]

I might be able to share my observations directed to the original post. I am a FNP and work both in a UC independent, often alone as the sole provider, we have CT, ultrasound, labs, Rn, staff et et. Fairly reasonable resources. My group allows me to do what I am comfortable with and have training for, Fracture reductions, closed , no screening or triage if my partner of the day is a MD, NP or PA, fair amount of abd pain/chest pain workups....lots of debate of current literature with R /O issues for abd pain, MI, and PE workups.

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My other position is in a ED.

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When I work in the ED which is a different hospital system, it is a level one trauma center with a EM residency program, the NP's work the medicine side for the most part,,if my patient needs to be intubated, or tapped one of the EM residents generally gets pulled for the procedure practice. We still manage the patient but the ED attending gets a bit involved. Depending on acuity. They do not "allow" the NP's or PA's for the most part to work up trauma as they save those patients for the EM residents to practice on. It feels a bit restrictive as there is minimal learning....in a way...course I learn every day there, but little formal teaching. I find it interesting that in a state as I am with independent practice for NP's they limit our use, but also understand the need for the EM residents to obtain procedure practice that they have been in school for.... Curiously I also see a oversupply of EM residents emerging at least in this market that may encroach/compete for the NP role..Except that we cost less and have the same outcomes.....

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For the two cents its worth and 500plus fee I am applying by portfolio for the ENP, I personally think it fairly useless , as I do the DNP. If I want to go back to school I would get a Ph.D, that being said I feel it might pad my résumé, and since I meet the qualifications....I might as well....500 $ poorer....

[RN-CEN TS]

1. I would suggest you site your references before posting a hastily made reply as YOU are "nor" (I believe you meant "not") even an NP yet.

2. Secondly, I said "roughly half the states do not allow NP's to prescribe schedule II medications." You are correct concerning the ability to prescribe schedule II, In my mind I was thinking without restriction such as amount, doses, or ability to give refills. If calculating completely unrestricted states it would be close to "roughly half". But like I said, any ability to prescribe schedule II INCLUDING SET LIMITS WITH RESTRICTIONS, your statement is correct. Here is my resource:

http://www.deadiversion.usdoj.gov/drugreg/practioners/mlp_by_state.pdf

3. I should have instead said "some states dictate FNP practice to primary clinics" and I also should have said "MANY FNP practice outside of their scope of practice in those states".

4. If I was practicing in my state (OK), as a AGACNP/FNP (which I am currently not as you correctly assumed) and had a pediatric patient present with an acute complaint I would not see them because I am guided by the law in my state that governs my scope of practice. I would hand the patient over to someone who could see them legally within their scope of practice. Not that a AGACNP/FNP would not be competent to care for this patient, but because it would be against the law, unethical, and unprofessional to violate ones scope of practice.

5. There is no doubt that FNP are the sole provider in many ED's across the country, and as I posted I believe most are competent to do so. The OP had questions about which degree/cert to acquire to practice in the ED/ER. My intentions were to help the OP navigate the perplexity of differences from state to state as evidenced by the different nurse practice acts that guide all ARNP's to get the most accurate and legal answer, and enable her to make an informed, evidenced based decision.

6. The national certification "ENP-BC" is not obtained by a post graduate program specific to emergency care. It is solely by being a ARNP of any kind, that is nationally certified, and providing previous work documentation in the ED. Even the credentialing body states it does not replace your primary test certification by any means.

I do not need to finish school to understand, or make more sense of this information. I have researched this topic heavily prior to application and acceptance into my program as these issues will shape my career path. I agree with you nomadcrna that many of these things do not make sense and there should be no differences state to state on how ARNP, or CRNA's practice. Unfortunately, we have 51 sets of rules and currently have to follow them as our guide to how, who, and where we practice. Hopefully in the future there will be finite rules and legislation that provide uniformity across the United States that will eliminate all inconsistencies from state to state.

Also, thank you for your concern and well presented post.

[tryingtohaveitall]

Thought better and decided I didn't need to be petty

[hunnybaby24, BSN, APRN, NP]

do midlevels in the er always do rotating shifts? that just seems pretty hard on the body.

[RN-CEN TS]

In my ER which has an MD residency, all physicians have rotating shifts, attendings and residents alike. I don't think it is uncommon for ED providers to do so based on the hours they work (few in comparison to other specialties) and their high level of compensation (compared to most other specialties). I would think it would be common for midlevels as well, but probably contract dependent and what the use of midlevels revolve around in their ED.

[applesxoranges, BSN, RN]

We have FNP in my old rural ER but they worked more of the fast track side except the occasional time the doctor would ask them to help out (1 doctor at that ER at any time and no residents). They would sometimes beg the NP to come in early.

The NP there said that they could only hire FNP in the ER because they could see across all ages where as a pediatric or an adult one would be limited.

The physician group in my current ER will not hire NPs but will hire PAs. The hospital system in general will hire NPs and PAs and post the jobs as a midlevel provider. Other physician groups like the big one that covers has NPs in their practice and they can admit for the group.

The other hospital system seems to be in love with CNMs and NPs. They actively use them in everything. My instructor for OB was a NP for the NICU and she was well known in the OB units because she goes on high risk births in the system.

[nomadcrna, DNP, CRNA, NP]

The American Association of Nurse Practitioners (AANP) opposes use of terms such as “mid-level provider” and “physician extender” in reference to nurse practitioners (NPs) individually or to an aggregate inclusive of NPs. NPs are licensed, independent practitioners. AANP encourages employers, policy-makers, health care professionals and other parties to refer to NPs by their title. When referring to groups that include NPs, examples of appropriate terms include: independently licensed providers, primary care providers, health care professionals and clinicians.

Terms such as “mid-level provider” and “physician extender” are inappropriate references to NPs. These terms originated in bureaucracies and/or medical organizations; they are not interchangeable with use of the NP title. They call into question the legitimacy of NPs to function as independently licensed practitioners, according to their established scopes of practice. These terms further confuse the health care consumers and the general public, as they are vague and are inaccurately used to refer to a wide range of professions.

The term “mid-level provider” (mid-level provider, mid level provider, MLP) implies that the care rendered by NPs is “less than” some other (unstated) higher standard. In fact, the standard of care for patients treated by an NP is the same as that provided by a physician or other health care provider in the same type of setting. NPs are independently licensed practitioners who provide high-quality and cost-effective care equivalent to that of physicians. 1,2 The role was not developed and has not been demonstrated to provide only “mid-level” care.

The term “physician extender” (physician-extender) originated in medicine and implies that the NP role evolved to serve as an extension of physicians’ care. Instead, the NP role evolved in the mid-1960’s in response to the recognition that nurses with advanced education and training were fully capable of providing primary care and significantly enhancing access to high-quality and cost-effective health care. While primary care remains the main focus of NP practice, the role has evolved over almost 45 years to include specialty and acute-care NP functions. NPs are independently licensed, and their scope of practice is not designed to be dependent on or an extension of care rendered by a physician.

In addition to the terms cited above, other terms that should be avoided in reference to NPs include “limited license providers,”“non-physician providers,”and“allied health providers.” These terms are

all vague and are not descriptive of NPs. The term “limited license provider” lacks meaning, in that all independently licensed providers practice within the scope of practice defined by their regulatory bodies. “Non-physician provider” is a term that lacks any specificity by aggregately including all health care providers who are not licensed as an MD or DO; this term could refer to nursing assistants, physical therapy aides, and any member of the health care team other than a physician. The term “allied health provider” refers to a category that excludes both medicine and nursing and, therefore, is not relevant to the NP role.

1. AANP (2013). Nurse practitioner cost-effectiveness. Austin, TX: AANP. 2. AANP (2013). Quality of nurse practitioner practice. Austin, TX: AANP. For more information, visit aanp.org.