FNP doing procedures

BlueDevil,DNP, DNP, RN · Mar 16, 2012

Well, like I said I knew it would vary between states and it goes unsaid that it would vary between institutions.
I guess those procedures are just not taught then. It's obvious that an FNP would have to take histories and physicals, etc. I just wondered where, if ever, the procedures that you could have done at your family practitioner's (MD) clinic were taught to FNP students. I'm assuming by the replies that joint aspirations, would debriedment, endoscopies, and so forth aren't done at all by FNPs. ?? Thanks for the replies, ladies.

Disclaimer, I am an independent practitioner in family practice.

I do arthocentesis and intra-articular injections several times a week. I also do a lot of shave and punch biopsies, colposcopy, IUDs, I&Ds, and botox and fillers. Yesterday I removed several large sebacious cysts (and sacs) that required suturing afterward. My rule of thumb is, if it were something I'd want a plastics expert to do for myself or my kid, I refer it to plastics. I do not generally sew faces, except in cases like the patient that insisted he didn't care about the scar and just wanted his eyebrow sewn back on in a hurry, lol. I had suturing in school but I didn't get good at it until I practiced. I had several weeks worth of instruction on reading xrays in school. I am expected to do a preliminary read on my my own films, but like my colleagues, I rely on my own interpretation only to assess the highlights and defer to the radiologist for the final word. This too was a skill I learned with practice and reinforcement from people with more experience. Someone brought me copies of his head CT earlier this week and I honestly wondered what he thought any of us in a primary care office would do with them, lol. I just told him I was clueless about them. If that true solely because I am not a MD provider, well I can live with that and he will too.

I do agree that gross anatomy would have been great fun and a thrilling learning experience. It's a pity that it isn't available to NP students but as I understand it, it is very difficult to get the number of cadavers needed for medical students as it is. Clearly, if they are to be rationed, it makes sense to appropriate these limited resources to medical students.

nomadcrna, DNP, CRNA, NP · Mar 16, 2012

Yes to all you asked.

suturing is pretty basic. I'm not sure how you can even do clinic without this skill.

Casting, splint, joint injections, aspirations, I&D, minor office surgeries, xray interpretation are all skills you need in the clinic.

I don't do endoscopies but there is an FNP in the large city near where I am that does a fantastic job. She was taught at that hospital.

If you solo ER, you need to be proficient in intubations, chest tubes, central lines, trauma resuscitation etc.

You do not need a physician, period. At least in the states that I choose to work.

As others have said, much depends on the state and facility credentialing. Facilities can be tough. I always work to change the bylaws to be NP friendly.

Where I currently practice. NPs are full members of the med staff. We admit and manage our own patients. It is a great practice.

You just need to figure out a way to get the education and training. There are intensive courses but the best way is to have a mentor who can teach you and lots of opportunities to practice.

If you have an OR, talk to the CRNA. I was always happy to teach NPs to intubate and let them practice.

I'm interested in the midlevel provider role in healthcare so obviously I'm examing the PA and NP professions with FNP being the part of advanced practice nursing that interests me. Out of curiosity, and I know things differ between states, what procedures do FNPs practice in comparison to PA or phyisicians. For example, it seems I've seen some skepticism in FNPs suturing patients, etc. Do they do that, cast, splint, joint injections, aspirations, debriedments, endoscopies, etc.? If they work in emergency departments, in say more rural areas, would they be doing chest tubes, intuabations, and so forth if the need be alongside a physician or perhaps in place of one? Finally, I've looked at the curriculum for FNP programs at many universities, and I wonder where the training to interpret x-rays and other imaging diagnostics may come from particularly since there is no gross anatomy component to FNP programs. I'm aware of the different "models" used to train nurses and PAs, but I haven't exactly seen a listing of what FNPs may be doing other than "ordering and interpreting tests, diagnosing and prescribing."
Lots of questions there, I know. Hoping some of you may can answer them. Thanks!!

nomadcrna, DNP, CRNA, NP · Mar 16, 2012

First I've heard of NP organizations encouraging state boards to limit FNP practice. Do you have link or article to back this up?

More states allow full practice as long as you can back it up with education or training.

Rural areas have a great need and FNPs full a role. Part of primary care IS admitting and managing your patients.

Most rural hospitals WANT the FNP to be well rounded and able to "do it all".

The training, role and practice of Family Nurse practitioners is grounded in primary care. The national NP organizations are encouraging State Boards of Nursing to limit the practice of FNPs to primary care settings, and more employers are encouraging their present staff with FNP certification working in inpatient areas or specialty clinics to go back to school and obtain ACNP certifications.
If the OPs true love is the procedural arena, then a FNP program may not be the best choice.

nomadcrna, DNP, CRNA, NP · Mar 16, 2012

American Academy of Nurse Practitioners

Nurse Practitioners in

Primary Care

Administration

P.O. Box 12846

Austin, TX 78711

P 512.442.4262

F 512 442.6469

Office of Health Policy

P.O. Box 40130

Washington, DC

20016

P 202.966.6414

F 202.966.2856

With 89% of the nurse practitioner (NP) population prepared in primary care and over 75% of

actively practicing NPs providing primary care, NPs are a vital part of the U.S. primary care

workforce. Evidence supports the high quality and cost-effectiveness of NP care and the continued

interest of the discipline to contribute to solving the primary care dilemma.

Ninety percent of the 140,000 NPs credentialed

to practice in the U.S. are actively practicing.

Fulfilling the potential of the Affordable Care Act

(ACA) requires transformation of primary care

delivery within the U.S. NPs are a vital element

of the primary care workforce with a major role

in making high-quality, patient-centered health

care available to the broadest possible range of

consumers. In fact, NPs make up the most

rapidly growing component of the primary care

workforce. As licensed independent providers

prepared with a blend of medical and nursing

preparation, NPs are uniquely prepared and

qualified to provide the patient-centered care

that is central to meeting the existing and future

primary care needs of our nation.

NP Scope of Practice and Preparation

The NP scope of practice includes blending

nursing and medical services for individuals,

families, and groups. NPs diagnose and manage

acute and chronic conditions and emphasize

health promotion and disease prevention. Their

services include, but are not limited to ordering,

conducting, and interpreting diagnostic and

laboratory tests; prescribing pharmacologic

agents and non-pharmacologic therapies; and

teaching and counseling. They practice

autonomously and in collaboration with other

healthcare professionals to manage patients’

health needs.

NPs are prepared through academic graduate

(master’s or doctoral) programs, which include

didactic and clinical courses designed to prepare

graduates with specialized knowledge and clinical

primary care competencies. Members of the

profession are responsible for advancing the NP

role, specifying the professional standards and

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met.

NP Commitment to Primary Care

Almost all NPs (89%) are prepared in a

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Family 49.2

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Oncology 0.8

Pediatric 9.4

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Women’s Health 9.1

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nomadcrna, DNP, CRNA, NP · Mar 16, 2012

http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Advanced_Practice_in_Emergency_Nursing_-_ENA_White_Paper.pdf

Advanced practice registered nurses working in emergency settings are experienced providers. In a

survey of 166 advanced practice registered nurses who worked in emergency departments,

approximately two-thirds (63%) of the respondents were nurse practitioners, 28% were clinical

nurse specialists, and 9% were both nurse practitioners and clinical nurse specialists.

8

The

respondents had practiced professional nursing for about 15 years before becoming advanced

practice registered nurses, and most had worked as an advanced practice registered nurse in the

emergency department for more than 5 years.

8

Currently, there are no national specialty

certifications for nurse practitioners or clinical nurse specialists practicing in emergency care

settings; however, many advanced practice registered nurses hold a national certification for

practice as a nurse practitioner or clinical nurse specialist. Advanced practice registered nurses in

emergency settings reported being certified most often as family nurse practitioners (43%), acute

care nurse practitioners (13%), adult care nurse practitioners (12%), pediatric nurse practitioners

(7%), women’s health nurse practitioners (

medical-surgical clinical nurse specialists (5%), pediatric clinical nurse specialists (

other clinical nurse specialists (10%).

8

LiLoRN · Mar 16, 2012

National Organization of Nurse Practitioner Faculties: Consensus Model for APRN Regulation

If you look here, you can see what the National Organization of Nurse Practitioner Faculties has to say about scope of practice for Acute vs Primary NP's. I'm attending FNP school, and the administration there is adament that we are being prepared only for outpatient primary care and won't even allow us to do clinicals in a hospital. They also state that when they receive requests for recommendations from hospitals about possible employment for grads, they reply to them that we are trained only for outpatient primary care.

nomadcrna, DNP, CRNA, NP · Mar 16, 2012

I am familiar with the consensus model. We are discussing it at our state board now. A few states have passed it but it remains to be seen if more do the same. Many rurual states (mine included) do not like the wording as many ERs ar staffed by FNPs.

The model is meeting much resistance in our state and may not pass.

If you read it, you will see that the FNP can still do ER and inpatient care. Intensive care will not be within the scope though.

It remains to be seen if the states will jump on board with the consensus model.

I am against it until the NP schools get their act together. A much better model would be a broad based basic program that incorporates all populations then specialize afterwards. The DNP is a perfect road to that end.

focus. For example, a family CNP could specialize in elder care or nephrology; an Adult-Gerontology CNS could specialize in palliative care; a CRNA could specialize in pain management; or a CNM could specialize in care of the post-menopausal woman. State licensing boards will not regulate the APRN at the level of specialties in this APRN Regulatory Model. Professional certification in the specialty area of practice is strongly recommended.

An APRN specialty

• preparation cannot replace educational preparation in the role or one of the six population foci;

• preparation can not expand one’s scope of practice beyond the role or population focus

• addresses a subset of the population-focus;

• title may not be used in lieu of the licensing title, which includes the role or role/population; and

• is developed, recognized, and monitored by the profession.

New specialties emerge based on health needs of the population. APRN specialties develop to provide added value to the role practice as well as providing flexibility within the profession to meet these emerging needs of patients. Specialties also may cross several or all APRN roles. A specialty evolves out of an APRN role/population focus and indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations, etc.).

Education programs may concurrently prepare individuals in a specialty providing they meet all of the other requirements for APRN education programs, including preparation in the APRN core, role, and population core competencies. In addition, for licensure purposes, one exam must assess the APRN core, role, and population-focused competencies. For example, a nurse anesthetist would write one certification examination, which tests the APRN core, CRNA role, and population-focused competencies, administered by the Council on Certification for Nurse Anesthetist; or a primary care family nurse practitioner would write one certification examination, which tests the APRN core, CNP role, and family population-focused competencies, administered by ANCC or AANP. Specialty competencies must be assessed separately. In summary, education programs preparing individuals with this additional knowledge in a specialty, if used for entry into advanced practice registered nursing and for regulatory purposes, must also prepare individuals in one of the four nationally recognized APRN roles and in one of the six population foci. Individuals must be

APRN Joint Dialogue Group Report, July 7, 2008

13

recognized and credentialed in one of the four APRN roles within at least one population foci. APRNs are licensed at the role/population focus level and not at the specialty level. However, if not intended for entry-level preparation in one of the four roles/population foci and not for regulatory purposes, education programs, using a variety of formats and methodologies, may provide licensed APRNs with the additional knowledge, skills, and abilities, to become professionally certified in the specialty area of APRN practice.

nomadcrna, DNP, CRNA, NP · Mar 16, 2012

That is a shame. I did a huge amount of ER and inpatient medicine in my program. I was with two great family practice docs who literally did it all. I did clinic with them, followed the inpatients and did many hours in the ER with them as well.

National Organization of Nurse Practitioner Faculties: Consensus Model for APRN Regulation
If you look here, you can see what the National Organization of Nurse Practitioner Faculties has to say about scope of practice for Acute vs Primary NP's. I'm attending FNP school, and the administration there is adament that we are being prepared only for outpatient primary care and won't even allow us to do clinicals in a hospital. They also state that when they receive requests for recommendations from hospitals about possible employment for grads, they reply to them that we are trained only for outpatient primary care.

KCEG · Mar 17, 2012

This is a very interesting topic to me personally.

I am getting ready to apply to Vanderbilt's PreSpecialty FNP Program, and was told at their open house that they are working with the TN BON to clarify FNP and ACNP training and scope of practice.

The Director of the ACNP program told me that in TN FNP's had no business practicing in the ED or working as a hospitalist, and she said that the BON is working to clarify the appropriate environments for Advanced Practice Nurses.

I currently plan to return to Texas unless an attractive offer presents itself in an unrestricted state, and know several hospitals here where FNP's work in the Emergency Room, and as hospitalists, especially in facilities that are located outside metropolitan areas.

Flexibility is high on my list of priorities when looking at Advanced Practice Opportunities after working in healthcare most of my career, and I'm not sure how concerned I should be with the information I've been hearing in relation to practice areas and restrictions.

If a graduate is not academically trained in school to provide care to inpatients and ER's, is it possible to obtain this training after graduation by working in places that offer learning opportunities? How much of this is dictated by facilities and credentialing, as opposed to Boards of Nursing? Is it necessary to return for ACNP certification and be dual-credentialed to be "qualified" under the scenario that is being described?

I apologize for all of the questions, but any insight that can be provided by currently practicing FNP's would be greatly appreciated. It seems there is significant confusion and difference of opinion from person to person and state to state on this issue.

Thank you,

KCEG

nomadcrna, DNP, CRNA, NP · Mar 18, 2012

Dual credentialling is your best bet. Vanderbilit has a nice dual program.

Many states you won't have an issue unless you try to work as an intensivist. But ER and inpatient has never been a problem for me.

Inpatient especially as that is an extension of primary care. ER may be more iffy in the future although fnPs are the only NPs that can really do it due to age restrictions.

CCRNDiva, BSN, RN · Mar 18, 2012

I went to an open house at Vanderbilt last year and they were very explicit about the roles of FNP and ACNP. My current school divides their focus as well. You can "specialize" your clinical experiences but only with additional coursework and clinical hours. For instance, a FNP or ANP can focus on cardiology, oncology, or emergency but only with taking the additional courses and clinicals for those specialties. The ACNPs can choose to focus on critical care or emergency.

I find that the medical arena is trending the same way. Family practice docs do not do many procedures in my area. Most FPs do not even round on their own hospitalized patients here. They may suture small wounds or do small biopsies, but often you are referred to a specialist. If you need an endoscopy, you are referred to GI. Many docs are not allowed to independently manage patients in the ICU. They have to submit proof of applicable training or education to be credentialed to independently manage critically ill patients. My son had a cyst on shin, we were referred to a GV surgeon. It all goes back to training. The days of the generalist being the jack of all trades is over. Residents are not able to get the training to learn how to manage everything with the limitations on hours. I've had the opportunity to work with many docs in my area and if I'm admitted to the ICU, I want a board certified intensivist, trauma surgeon or the like coordinating my care. I've seen a difference in the quality of care provided by the FPs in comparison to those whose training programs focused on critical care or the like. That doesn't mean they're bad docs, they just don't have the training or experience with procedures or critically ill patients.

nomadcrna, DNP, CRNA, NP · Mar 18, 2012

Yep, urban areas are that way. Probably for the best.

Rural areas though are a whole different ball game.

I agree. A specialist would be idea. Come to a rural area and try to find one. Try to find a residency trained ER physician. You won't find them. Look around for a hospitalist,nope. There is not even a surgeon in our town.

Do you want NO care or at least some care until you are transfered out?

There is more to the medical world then big urban cities.

Nobody is talking about FNPs or family practice physicians providing sole care in a urban ICU. Not anytime as that been mentioned. We are discussing FNPs doing RURAL ER and inpatient.