Work as NP and bedside nurse

meanmaryjean, DNP, RN · Oct 15, 2013

I know several people who split their time between bedside and advanced practice. It can be done!

allnurses Guide · Oct 15, 2013

I have several colleagues that do.

You need to check with your state BON as to what your liability is while holding an APN license and practicing as an RN.

Annaiya, NP · Oct 18, 2013

The BoN doesn't have any say over your liability, it is a legal standard. If you work as an RN but have an NP license you will be held to the knowledge and expertise of that of an NP if you ever got sued. However, it does not change the scope of practice for you as a RN, which could significantly increase your liability risk. If you work in a low liability area you'd likely be fine, but I wouldn't suggest working in an acute care setting.

core0 · Oct 19, 2013

The BoN doesn't have any say over your liability, it is a legal standard. If you work as an RN but have an NP license you will be held to the knowledge and expertise of that of an NP if you ever got sued. However, it does not change the scope of practice for you as a RN, which could significantly increase your liability risk. If you work in a low liability area you'd likely be fine, but I wouldn't suggest working in an acute care setting.

It actually does matter what the BON says. It also matters what the collaborative environment is. If the board holds you to the highest license then yes that matters. However, if you work in a state that says FNPs can't work inpatient then you couldn't be held to the inpatient standard working inpatient. Also some states require a collaborative agreement with a physician for each job. If you have no collaborative agreement then you are not working in the NP role. Each state takes a very different approach in how they deal with this. In essence the liability is determined by the role defined by the BON and the case law for the state.

MedictoRN · Oct 19, 2013

I have seen this topic come up many times over the years and have never really understood what the issue is. We are all nurses and are responsible for a standard if care despite your level of education. The standard doesn't change because you have a MSN or DNP. As many times as I have seen this come up I've never seen an example, real or hypothetical, that demonstrated an increased liability risk for an APRN working in an RN role. Seems like an urban legend to me.

joyfullpn · Oct 19, 2013

I'm not 100% positive but I was told that you can work as both and that's the reason why you have to also keep your RN license active when you're an NP.

Trauma Columnist · Oct 19, 2013

Here is an I depth survey by NSO regarding NP lawsuits

http://www.nso.com/pdfs/db/Nurse_Practitioner_Claim_Study_02-12-10.pdf?fileName=Nurse_Practitioner_Claim_Study_02-12-10.pdf&folder=pdfs/db&isLiveStr=Y

Everything I've read goes back to the individuals states practice act. And...my personal experience is that hospital risk management depts don't want to hire NPs to work as RNs due to the increased liability for the hospital.

MedictoRN · Oct 19, 2013

Here is an I depth survey by NSO regarding NP lawsuits http://www.nso.com/pdfs/db/Nurse_Practitioner_Claim_Study_02-12-10.pdf?fileName=Nurse_Practitioner_Claim_Study_02-12-10.pdf&folder=pdfs/db&isLiveStr=Y Everything I've read goes back to the individuals states practice act. And...my personal experience is that hospital risk management depts don't want to hire NPs to work as RNs due to the increased liability for the hospital.

I don't see where this references NPs in an RN role, just NPs working as NPs in various settings. I would have liked to see more statistical analysis of the data. They really just gave use the descriptive statistics without much analysis.

Annaiya, NP · Oct 19, 2013

If there is a state statue that specifically addresses the liability incurred by an NP who is working as an RN, then that would be persuasive in court. However, I have never seen a statute that addresses it. What I have seen are statutes that discuss RN and NP roles separately. That means if the issue comes up in court it is up for debate. Generally, in torts law there is a "reasonable person" standard. Meaning, what would a reasonable person in a given situation do. If you are an RN, the standard will be viewed as "what would a reasonable RN do?" If you are an NP working as an RN it will change to "What would a reasonable NP working in an RN role do?" See how different that is?

I have researched case law on a couple of RN liability issues and found almost nothing. Not unexpected, since RNs aren't sued very often and 95% of all med mal cases settle. So I'm guessing there isn't much if any to address this specific issue. This means if this type of case went to court the attorneys would try to find cases that are similar from other fields. This issue is not nearly as black and white as many of these posts seem to make it.

Core0, you are wrong about the lack of a collaborative agreement and the FNP working inpatient in a state that doesn't allow that. The issue is not if they are working as an NP, they obviously aren't, they are in an RN role. The issue is what knowledge is that specific person expected to have. Just because they are an FNP working an inpatient RN role doesn't change the fact that they should be able to interpret a CBC at a higher level than an RN. It's a higher expectation of knowledge that sets up the theoretical increased liability.

MedictoRN, it's definitely not an urban legend. And if I was the plaintiff's attorney and the person working in the RN role had a DNP, I would argue that they should be held to an even higher standard than an MSN. Court cases are about arguing your positions and trying to make your client look "in the right." I think med mal cases are pretty much always jury cases, since the plaintiff wants to pull on the heartstrings of the jury. The jury does not have to follow the letter or spirit of the law. Isn't it reasonable to think that a juror would be likely to think someone with a DNP should know more than someone with a MSN?

JoyfulPN, we have to maintain our RN licenses, because we are Advanced Practice Registered Nurses. The RN is the foundation of our expanded role, so we need to maintain that. It isn't so that we can work in an RN position.

I know some nursing schools have a legal class, but I really wish there was more ongoing legal education for nurses. It is amazing to me some of the things I have heard nurses say over the years about what can incur liability and what not. There is tons of misinformation and rumor that circulates around these issues. I think in part because the issues are not black and white, so people interpret what they hear in different ways, because they don't have a solid foundation of the legal system. I know my approach and the way I do things and chart things tends to be very different than some of my colleagues (at least when I was an RN). And I would consider working as an RN if I wanted to, the increased liability wouldn't stop me, but I would not work in critical care and I would be extra careful with my charting and reviewing of labs, diagnostics and my patient's status, because of it.

This is all completely my opinion and not at all legal advice, but I think I have an educated opinion as an attorney. Sadly it's been years since I've had access to Westlaw, or I'd do some case searches and let you know what I could find. If anyone does have Westlaw access (to the allcases database at least), feel free to PM me and I could suggest some searches to see if there are any cases on this issue. That would give us the most concrete answer to this question, although it would be state case law most likely and therefore not controlling in other jurisdictions. To me, the bottom line is nothing in law is ever black and white. It is always easy to argue why a statute doesn't apply or isn't being interpreted correctly, so just because the BoN says something doesn't mean it will hold up in court. Which is why I don't think what they say really matters, it's only 1 piece in a large puzzle. :)

MedictoRN · Oct 19, 2013

If there is a state statue that specifically addresses the liability incurred by an NP who is working as an RN, then that would be persuasive in court. However, I have never seen a statute that addresses it. What I have seen are statutes that discuss RN and NP roles separately. That means if the issue comes up in court it is up for debate. Generally, in torts law there is a "reasonable person" standard. Meaning, what would a reasonable person in a given situation do. If you are an RN, the standard will be viewed as "what would a reasonable RN do?" If you are an NP working as an RN it will change to "What would a reasonable NP working in an RN role do?" See how different that is?
MedictoRN, it's definitely not an urban legend. And if I was the plaintiff's attorney and the person working in the RN role had a DNP, I would argue that they should be held to an even higher standard than an MSN. Court cases are about arguing your positions and trying to make your client look "in the right." I think med mal cases are pretty much always jury cases, since the plaintiff wants to pull on the heartstrings of the jury. The jury does not have to follow the letter or spirit of the law. Isn't it reasonable to think that a juror would be likely to think someone with a DNP should know more than someone with a MSN?

I guess I can't imagine an example where this really applies. So a CBC comes back abnormal, as an RN, regardless of your education, you call the provider in charge of the patient and get an order. I would love to hear an example where this applies. Again, I've never seen any examples of anybody who even knows someone who this impacted. What about cases where an RN with an MSN, but not an NP, was held to a higher standard?

Psychcns · Oct 19, 2013

I can think of some examples. Say you are an APRN and you work prn in a LTC facility where your job is to give meds. 30 patients

What is your liability?? Say the charge nurse reviews the labs.. Since you are an APRN should you also review the labs.

It could get mucky...