ACNP scope of practice in the hospital defined

[bap9090]

Hello everyone, I really do hope that this topic is not redundant although I cannot seem to find a thread here that really answers my questions.

[COLOR=#3f4549]As an NP in the hospital setting, can you help me understand where the physician intervenes in the care of your patients? I am current in nursing school (RN) and I am specifically in becoming an AG-ACNP or an FNP. I am struggling with understanding the day to day experience as a provider in this role in acute care as I haven't really seen it yet. In my experiences, nurses have followed physician orders and collaborated care with them. I have not seen any NP's acting as the direct provider. I know that the details of this topic differ from state to state, but I would like to hear from anyone with relevant input. [/COLOR]

[COLOR=#3f4549]I understand that as the NP you can typically order diagnostics, medications, and create the plan of care for your patients. It is my understanding that anything that can show in the patient chart as an order can be entered by an NP or MD. How does the 'physician supervision' impact this? Do the bedside RN's provide patient status updates to the NP or the supervising MD? Do they request treatment/med orders from the providing NP or from the supervising MD? Does the MD review your plan or care and provide approval before implementation, do they make changes as they see fit? What procedures are within the NP scope of practice to order and complete independently? As I understand it, the NP can do most procedures that are not considered surgical. Does the NP make referrals to specialists, home care, OT, PT, RT, etc.? I get confused in understanding where the NP autonomy ends in the hospital/acute care settings.

Some people make it seem like the physicians are in the background and patient care belongs to the providing NP. Others make it seem as though the ACNP is a 'glorified RN', an actual term I've seen used, simply performing procedures in between the RN and MD scope of practice, being involved in the admission assessment and initial care planning, and leaving the rest to the attending. I know that NP's are quite autonomous in outpatient/primary care settings from my personal experience.

If you guys could help answer these questions and correct me where I'm wrong I really would appreciate it![/COLOR]

[Nurseboy1]

I'm an ACNP in the ICU at my hospital. I work primarily at night. Our practice model is that it is me and my attending for the whole unit. Generally I do most everything for the patients. If an admission comes I see them and take a history, I do the H&P, write the admission orders, if they need any procedures like central lines or a-lines I do them. My attending will see the patient and then we review my plan and make any modifications if the attending wants them.

My colleagues on the dayshift are the primary responsible ones for their patients. They present the patient on rounds, write the daily ICU note, do the orders and they also do the procedures that are needed.

I often go to the intermediate unit to do critical care consults for patients that are decompensating. I usually am the one doing any procedures. My attending is required to be in the room for high risk procedures such as intubations, PAC placement, or TVP placement but they aren't right at my side telling me how do to them or anything. I'm credentialed in central lines and A-lines and I do those without the doc in the room.

So at least in my unit I have a lot of autonomy. If I think the patient needs something I do it. I keep my attending in the loop as far as patient condition changes, they are ultimately responsible, but I'm far from a glorified RN.

[traumaRUs, MSN, APRN]

Moved to student NP forum

[bap9090]

I'm an ACNP in the ICU at my hospital. I work primarily at night. Our practice model is that it is me and my attending for the whole unit. Generally I do most everything for the patients. If an admission comes I see them and take a history, I do the H&P, write the admission orders, if they need any procedures like central lines or a-lines I do them. My attending will see the patient and then we review my plan and make any modifications if the attending wants them.

My colleagues on the dayshift are the primary responsible ones for their patients. They present the patient on rounds, write the daily ICU note, do the orders and they also do the procedures that are needed.

I often go to the intermediate unit to do critical care consults for patients that are decompensating. I usually am the one doing any procedures. My attending is required to be in the room for high risk procedures such as intubations, PAC placement, or TVP placement but they aren't right at my side telling me how do to them or anything. I'm credentialed in central lines and A-lines and I do those without the doc in the room.

So at least in my unit I have a lot of autonomy. If I think the patient needs something I do it. I keep my attending in the loop as far as patient condition changes, they are ultimately responsible, but I'm far from a glorified RN.

Thank you for your response! When I saw the "glorified RN' comment I was very taken aback, which is why I've been looking to hear from people in the profession. It can be hard to understand until you've really been immersed in the situation. Your day to day job sounds great. I think the style of physician supervision you experience is ideal, because it allows you to use your knowledge nursing focus to care for your patients, without medical intervention. That is the vision of the healthcare team that made me want to become an NP. Do you and your attending share the patient load so that he/she is solely responsible for a portion of the patients, or do you collaborate among the whole unit. If referrals are needed can you provide that, or does the attending have to make those recommendations?

[Nurseboy1]

Thank you for your response! When I saw the "glorified RN' comment I was very taken aback, which is why I've been looking to hear from people in the profession. It can be hard to understand until you've really been immersed in the situation. Your day to day job sounds great. I think the style of physician supervision you experience is ideal, because it allows you to use your knowledge nursing focus to care for your patients, without medical intervention. That is the vision of the healthcare team that made me want to become an NP. Do you and your attending share the patient load so that he/she is solely responsible for a portion of the patients, or do you collaborate among the whole unit. If referrals are needed can you provide that, or does the attending have to make those recommendations?

I primarily have responsibility for all the patients on our census. The nurses call me first with issues or needs for order clarifications. If I'm tied up with one patient and another patient needs help then the attending steps in. If I need help my attending is right there for me.

If we need consults, I put the order in and call the consulting doc and go over the patient situation with them.

[bap9090]

I primarily have responsibility for all the patients on our census. The nurses call me first with issues or needs for order clarifications. If I'm tied up with one patient and another patient needs help then the attending steps in. If I need help my attending is right there for me.

If we need consults, I put the order in and call the consulting doc and go over the patient situation with them.

Thanks so much for the feedback! I look forward to continuing my education and moving into the NP role. I am not sure if I'd rather do acute care or primary care, but I am sure I will enjoy it!