ACNP vs. PA for Surgery

djc1981 · Jul 8, 2008

Maybe David could help you out here. Or you could ask at physicanassistantforum.com for someone who would know more.

core0 · Jul 8, 2008

Im sure everyones seen plenty of PA vs NP threads, and since this is a nursing website all of the answers have favored the NP's for the most part. I would prefer to be involved in surgery. So I was looking to see if there was specialty PA programs and for the most part they are pretty general but I did see that there are residencies for PA's that can specialize in surgery. So I was wondering would that be a better route? It doesnt appear theres anything like that for nursing. Help me out!

All PA programs train you in general medicine however there are two PA programs that are surgery oriented, University of Alabama at Birmingham and Cornell. There are also post graduate programs in surgery that can be found here:

http://www.appap.org/prog_specialty.html

The real answer is more complex. Together all of the residencies and surgical PA programs produce around 100 new grad per year (not all of the surgical PA program graduates go into surgery). There were around 600 new grads in the last census so these programs probably account for less than 10% of new grad surgery students. The rest come from general PA programs. One issue is that a surgical rotation is required for all PA students. Depending on the program you may have several optional rotations where you can do surgery. Some programs in addition to the surgery rotation have a mandatory orthopedic surgery rotation. If you really want to do surgery it will probably be helpful to find a program that has as many optional rotations as possible to do more surgery rotations.

Most large groups are set up to train new grad PAs in surgery (especially orthopedics). Most groups will also train new grads that are interested in surgery depending on the market. A lot of these positions are found through rotations. There are several threads including a nice thread on the value of post grad programs over at the PA forum:

http://www.physicianassistantforum.com/forums/forumdisplay.php?f=302

David Carpenter, PA-C

straba · Jul 8, 2008

I'm an ACNP on a neurosurg service, and spend about 40-50% of my time in the OR. My facility sent me to an RNFA program to get me up to speed, and it's worked out well so far. We have both PA's and NP's on our service, and we all (with the exception of 1 PA) do our time in the OR. I guess it depends on where you work.

ncaru01 · Jul 8, 2008

I guess im confused, if nurses don't get that residency how do nurses come about getting a specialty in a certian type of surgery? Are they just trained on the spot? Would I be better off getting my BSN and applying to a PA school instead or acnp? It would require me to go another semester to school. I guess basically does it really matter?

Thanks for the other info really helpful

core0 · Jul 8, 2008

I guess im confused, if nurses don't get that residency how do nurses come about getting a specialty in a certian type of surgery? Are they just trained on the spot? Would I be better off getting my BSN and applying to a PA school instead or acnp? It would require me to go another semester to school. I guess basically does it really matter?
Thanks for the other info really helpful

For most hospitals the RNFA is the nursing certification required to work in the OR. However, this is not an NPP by Medicare standards and cannot bill Medicare for first assist. They can be reimbursed by other insurances. Medicare, rightly, views surgical care as care around the operation. NPs are capable of providing this care and do in some places. There are a few NPs that also work in the OR (around 1% of NPs). Generally they reach this through one of two methods. There are those that worked in the OR, already have their CNOR and RNFA and then go to NP school. The other way which used to be more common was that the surgeon would hire the NP then train them in surgery. With current JHACO interpretation, most hospitals are requiring RNFA before being allowed to assist. Since you have to have 2000 hours of experience assisting, this is kind of a catch 22. There may still be smaller hospitals that would allow this but it seems to be growing increasingly rare. The third option as an NP is the UAB RNFA/ACNP program.

There are a number of barriers to NPs working in surgery. The biggest is that most surgeons are very familiar with PAs and not familiar with NPs. There are also age issues involved with the ACNP certification being coupled to the RNFA. Many surgical practices see all ages. In an orthopedic practice for example the age range may be from toddler to geriatric. The lower limits of the age group are outside the scope of practice of the ACNP.

As someone who does medical management with occasional forays into surgery I can say its a very interesting life. For information on the RNFA look here:

http://www.cc-institute.org/cert_crnf.aspx

David Carpenter, PA-C

JDCitizen · Jul 9, 2008

For most hospitals the RNFA is the nursing certification required to work in the OR. However, this is not an NPP by Medicare standards and cannot bill Medicare for first assist. They can be reimbursed by other insurances. Medicare, rightly, views surgical care as care around the operation. NPs are capable of providing this care and do in some places. There are a few NPs that also work in the OR (around 1% of NPs). Generally they reach this through one of two methods. There are those that worked in the OR, already have their CNOR and RNFA and then go to NP school. The other way which used to be more common was that the surgeon would hire the NP then train them in surgery. With current JHACO interpretation, most hospitals are requiring RNFA before being allowed to assist. Since you have to have 2000 hours of experience assisting, this is kind of a catch 22. There may still be smaller hospitals that would allow this but it seems to be growing increasingly rare. The third option as an NP is the UAB RNFA/ACNP program.
There are a number of barriers to NPs working in surgery. The biggest is that most surgeons are very familiar with PAs and not familiar with NPs. There are also age issues involved with the ACNP certification being coupled to the RNFA. Many surgical practices see all ages. In an orthopedic practice for example the age range may be from toddler to geriatric. The lower limits of the age group are outside the scope of practice of the ACNP.
As someone who does medical management with occasional forays into surgery I can say its a very interesting life. For information on the RNFA look here:
http://www.cc-institute.org/cert_crnf.aspx
David Carpenter, PA-C

Not an argument but an observation: I would construe JHACO interpretation to be contradictory to written protocols required by certain state boards..

I would be curious on how a hospital accredation organization could trump state laws that are allowed by federal laws..

When I went through school there were two students there to become NPs most specifically for this reason. There schooling was paid for by their MDs for the primary purpose of assisting in the OR as well as their other duties. The doctors specifically wanted NPs and not PAs (I don't know why and I didn't ask). Of course things do/can change in 5 years...

core0 · Jul 9, 2008

Not an argument but an observation: I would construe JHACO interpretation to be contradictory to written protocols required by certain state boards..
I would be curious on how a hospital accredation organization could trump state laws that are allowed by federal laws..

When I went through school there were two students there to become NPs most specifically for this reason. There schooling was paid for by their MDs for the primary purpose of assisting in the OR as well as their other duties. The doctors specifically wanted NPs and not PAs (I don't know why and I didn't ask). Of course things do/can change in 5 years...

Jhaco is the 500 lb gorilla of the hospital world. What trumps everything is certification. If JHACO does not certify your hospital then Medicare does not pay for care at your hospital and it goes out of business. On the other hand if you look at the what the regulation actually says, its something very different. What the regulation says is that the hospital and in particular the OR must have a way of verifying competency. Ideally the OR would separately evaluate every provider. However, the "administrators" prefer an easier way. For PAs we have been successful in pointing out that surgery is part of the training for every PA and resisting any effort to require certification. For nursing the AORN has been allowed to dictate that competency. It shows a fundamental lack of understanding about the surgical milieu. Managing surgery patients is much more than the technical portion of the surgery. The pre and post op care is actually where the NPP is needed most.

There are NPs working in the OR (some even post here) but its rare. In three years as an OR tech I worked with more than 60 PAs and one NP. Its mostly about the statistics.

David Carpenter, PA-C

JDCitizen · Jul 9, 2008

Jhaco is the 500 lb gorilla of the hospital world. What trumps everything is certification. If JHACO does not certify your hospital then Medicare does not pay for care at your hospital and it goes out of business. On the other hand if you look at the what the regulation actually says, its something very different. What the regulation says is that the hospital and in particular the OR must have a way of verifying competency. Ideally the OR would separately evaluate every provider. However, the "administrators" prefer an easier way. For PAs we have been successful in pointing out that surgery is part of the training for every PA and resisting any effort to require certification. For nursing the AORN has been allowed to dictate that competency. It shows a fundamental lack of understanding about the surgical milieu. Managing surgery patients is much more than the technical portion of the surgery. The pre and post op care is actually where the NPP is needed most.
There are NPs working in the OR (some even post here) but its rare. In three years as an OR tech I worked with more than 60 PAs and one NP. Its mostly about the statistics.
David Carpenter, PA-C

I have gone through enough JHACO inspections to agree with the 500 lb gorilla comment. I have also been through enough of them to know they need themselves to be better organized. Even though this fact was brought up in congress a few years ago the gorilla still swings freely through the hospital jungle... But thats an topic for a different day :clown:

core0 · Jul 9, 2008

I have gone through enough JHACO inspections to agree with the 500 lb gorilla comment. I have also been through enough of them to know they need themselves to be better organized. Even though this fact was brought up in congress a few years ago the gorilla still swings freely through the hospital jungle... But thats an topic for a different day

The real problem is that these organizations are a classic example of the peter principle (people rise to the maximum level of their incompetence). If you can't hack it as a nurse you become a JHACO or Medicare inspector. One big problem is that the "experts" don't even understand what their own regulations and impose their own "interpretations" on the regulations. If you show them where their "interpretation" conflicts with what their regulation actually says, then they get insulted, become hypercritical and you fail the inspection. The ultimate power for the incompetent.

Apparently you're not allowed to tell them, "you're so stupid I wonder how you remember to breath" either. But thats a different story.

An even bigger problem is that if your organization actually listens to (and pays) self styled JHACO or Medicare "consultants".

David Carpenter, PA-C

jer_sd · Jul 9, 2008

One hospital that i have privilages as a NP includes first assisting. The other requires proof of NP, CNOR and completion of a RNFA program. Neither requires CRNFA certification (2000 hours practice as previously mentioned) for NPs. They do credential RNFAs also.