AGAC, AGPC, or FNP?

[NewRookie, RN]

I am an RN and I want to work as an NP with ER and trauma patients. Which program would you recommend? AGAC, AGPC, or FNP?

[FullGlass, BSN, MSN, NP]

If you want to work in the ER, then you must choose an Acute Care specialty.  Do not do the FNP program, as that is for primary care.  

Frankly, you would be better off going for a PA program.

Acute Care NP is either Adult or Peds, but not both.  There has been discussion on this forum about NPs who are qualified in both, and the programs they went to, so search for this.

Best wishes

[FiremedicMike, RN, EMT-P]

FullGlass said:

If you want to work in the ER, then you must choose an Acute Care specialty.  Do not do the FNP program, as that is for primary care.  

Frankly, you would be better off going for a PA program.

Acute Care NP is either Adult or Peds, but not both.  There has been discussion on this forum about NPs who are qualified in both, and the programs they went to, so search for this.

Best wishes

Fyi FNP makes up the majority of NPs in the ED. 

[NewRookie, RN]

FiremedicMike said:

Fyi FNP makes up the majority of NPs in the ED. 

That's what I've heard, which is is why I asked.

FullGlass said:

Frankly, you would be better off going for a PA program.

Why do you say that? Thank you!

[FiremedicMike, RN, EMT-P]

NewRookie said:

That's what I've heard, which is is why I asked.

I think you need to be more clear about what you want.  If you want to be a trauma NP, responding down to the ED for trauma alerts, then admitting them and coordinating their inpatient care through discharge, then you need to go ACNP.  

[FullGlass, BSN, MSN, NP]

FiremedicMike said:

Fyi FNP makes up the majority of NPs in the ED. 

I'm not sure where you are getting that information.  FNPs are NOT educated or trained in acute care.  They should not be working in an ER.  If they work in the ER, and there is a liability issue, like a malpracticue lawsuit, then that FNP is going to be in big trouble legally, and so is the ER

FiremedicMike said:

I think you need to be more clear about what you want.  If you want to be a trauma NP, responding down to the ED for trauma alerts, then admitting them and coordinating their inpatient care through discharge, then you need to go ACNP.  

I'm curious - where are the ACNP programs?  There are ACNP peds and ACNP adult programs, but I haven't found a general ACNP program.  

NewRookie said:

That's what I've heard, which is is why I asked.

Why do you say that? Thank you!

Because the PA program does not separate out adults vs peds.  You learn all ages.  PAs also do way more procedures than NPs, including some surgeries.  Those are very useful skills for a provider working in a hospital.

Also, if you are FNP that works in an ER, you are working outside the scope of your education and training.  I don't care what an ER says if they hire you.  If you are sued, then you are toast, as the opposing counsel is going to make it very clear that you are not qualified to work in an ER.

[FiremedicMike, RN, EMT-P]

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I'm not sure where you are getting that information.  FNPs are NOT educated or trained in acute care.  They should not be working in an ER.  If they work in the ER, and there is a liability issue, like a malpracticue lawsuit, then that FNP is going to be in big trouble legally, and so is the ER

The overwhelming majority of ED patients are not even close to acute, but are essentially primary care patients who either don't have a PCP or don't want to wait for their PCP.  Midlevels (or APPs depending on your vernacular) in the ED are most frequently handling the soft 3s, the 4s, and the 5s, in order to speed up the overall throughput of the ED, leaving the acute care patients to the ED physicians.  There are obviously exceptions to this rule, but it is generally the NPs or PAs who have significant experience or those who go on to earn residencies or specific emergency certifications.  From the physicians I've talked to, they don't really love having an ACNP in the ED because they can't legally handle kids and they'd rather have them move the 3-5 patients as previously mentioned.

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I'm curious - where are the ACNP programs?  There are ACNP peds and ACNP adult programs, but I haven't found a general ACNP program.

Well there again, the OP needs to consider whether they want to work in peds or adult.  I shorten AGACNP to ACNP because my plan is to work inpatient trauma/SICU in an adult facility.

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Also, if you are FNP that works in an ER, you are working outside the scope of your education and training.  I don't care what an ER says if they hire you.  If you are sued, then you are toast, as the opposing counsel is going to make it very clear that you are not qualified to work in an ER.

This is just not accurate advice.  I've been in the EMS field for 25 years, worked closely with ED physicians and NPs as mentors for about 10 years, and directly as an ED RN for the last year and a half.  I don't mean to be rude, but you just aren't correct.

 

[FullGlass, BSN, MSN, NP]

FiremedicMike said:

The overwhelming majority of ED patients are not even close to acute, but are essentially primary care patients who either don't have a PCP or don't want to wait for their PCP.  Midlevels (or APPs depending on your vernacular) in the ED are most frequently handling the soft 3s, the 4s, and the 5s, in order to speed up the overall throughput of the ED, leaving the acute care patients to the ED physicians. 

I was an AGPCNP and am now a PMHNP.  When completing the NP Program at Johns Hopkins, our professors told us very clearly that we were NOT qualified to work in acute care in an ED.  We weren't, and that is the brutal truth.  Primary care NPs, and FNP is a primary care specialization, have absolutely no education in acute care issues, nor do they do any clinical rotations in an ED or other hospital setting.  We were told by our faculty that some EDs hire NPs, saying they will get the required training, but that AGPCNPs and FNPs should not do this, because they are practicing outside the scope of their education and training.  There are serious liability issues to consider.

The closest that an FNP would come to ED-type experience is Urgent Care.  However, not all NP students get an Urgent Care rotations.  In addition, most Urgent Care clinics will not hire a new grad NP, but require at least 2 years of NP experience before being considered for an Urgent Care position.

Johns Hopkins now offers a Dual DNP for Peds with both primary care and acute care covered, so that could be an option, but it is only for Peds.

I believe there are some other NP programs for Acute Care NPs that prepare them for both adult and peds.

Just because some EDs are hiring FNPs does not mean that it should be done.  The only way that might work is if the FNPs are clearly handling only the "Urgent Care" type cases that present in the ED.  

The number of high-acuity patients for whom nurse practitioners (NPs) are providing care in the ED is rising, according to a group of researchers who analyzed billing codes logged from 2015 to 2018.1 The level of acuity among patients became worse over the same period, according to the severity of the codes used to bill for the care provided. In contrast, acuity levels for patients who saw emergency physicians (EPs) decreased over time.

"That does not seem to make sense, and doesn't seem to be the way NPs were intended to be used in the ED. The original concept is that the NPs see the patients who, if we had adequate primary care physicians, would be seen in the primary care setting,” asserts Roberta P. Lavin, PhD, MA, RN, FNP-BC, FAAN, one of the study authors. . . There are two important considerations. One, is the care the NP provides and submits bills for within the scope of practice for NPs? Two, does the care reflect what the NPs are credentialed to do based on their competencies?  . . . 

In some malpractice cases, the allegation is NPs staffing the ED fast track failed to recognize subtle symptoms or lab results that merited sending the patient through the regular ED for an EP evaluation. "We see the same allegations against NPs as we do ED physicians; however, the added claim is a failure to consult with the attending physician,” says Amy Evans, JD, executive vice president of business development and liability claims at Intercare Insurance Services in Bellevue, WA.

Most plaintiff attorneys also name the supervising EP in these lawsuits . . . If an ED malpractice claim is filed, and an NP was involved in the patient's care, the NP's liability exposure will depend on how closely the NP was involved in the care, and also on hospital policies and state law. . . If a state nursing board becomes aware that an NP is practicing outside his or her scope in the ED, the board will initiate an investigation."

https://www.reliasmedia.com/articles/nurse-practitioners-working-in-ED-pose-unique-legal-risks

From AANP:

"An ENP is a board-certified advanced practice registered nurse (APRN) who treats patients of all ages in emergency departments (EDs) or urgent care facilities in collaboration with an interdisciplinary team. ENPs practice in community EDs, trauma centers, critical access hospitals and urgent care clinics. These practice settings require ENPs to work long hours — including night shifts, weekends and holidays — and to be on call.

Since the majority of patients who are seen in EDs are treated and discharged with minor health problems, ENPs must be prepared to provide primary care services, including managing patients with chronic disease conditions, caring for women with obstetric and gynecological problems and caring for infants and young children, who make up a significant percentage of all ED patients. However, ENPs must also be prepared to initiate care for patients with urgent, higher acuity illness, traumas and injuries and to provide acute resuscitation and stabilization of patients with life-threatening emergencies.

Most ENPs are family nurse practitioners (FNPs) who obtain additional emergency specialty education either through the completion of an academic or post-graduate fellowship program or through on-the-job training and continuing education (CE). Nurses interested in pursuing ENP preparation and board certification must first obtain certification as an FNP. Then, you can select from a growing number of academic and post-graduate ENP specialty training programs.

While, like all FNPs, ENPs are prepared to provide primary care services — such as educating patients, managing acute and chronic diseases and prescribing treatments — ENPs must also understand how to recognize and quickly manage complex patient needs. The pace of care translates to ENPs typically seeing a higher number of patients per shift and prescribing a greater number of medications. ENPs must also be masters at multitasking, prioritization and working within a care team."

https://www.AANP.org/news-feed/are-you-considering-a-career-as-an-emergency-nurse-practitioner

So, my take-aways:

1.  An FNP that wants to work in the ED needs to be very clear on their states' laws and regulations around this.

2.  An FNP needs additional certification for ED work.

3.  I was confusing general Acute Care versus ED.

4.  An FNP that just jumps into working in an ED is a serious liability issue/risk.

It just seems PA would be the easier route for this.  PAs are also qualified to provide primary care.

My previous career was business executive, so I am very conscious of liability.

[FiremedicMike, RN, EMT-P]

I dunno what to tell you, your anecdotal experience from what a professor told you does not mirror what is happening every day in ED's.

I'll certainly acknowledge that my area of the country could be different than everywhere else, but I seriously doubt it.

[FullGlass, BSN, MSN, NP]

FiremedicMike said:

I dunno what to tell you, your anecdotal experience from what a professor told you does not mirror what is happening every day in ED's.

I'll certainly acknowledge that my area of the country could be different than everywhere else, but I seriously doubt it.

A key point is that different states may have different laws and regulations around this, so any FNP who wants to work in an ER needs to be aware of this.

The other key point is that the OP states they want to treat trauma victims.  That is not primary care, it is acute care.  That is very different from what you were talking about.  In that case, I would advise the OP to become a PA, as that is the role better suited for trauma care.  FNPs have NO education or training in true emergency care, and I think trauma care fits into that category.  An FNP working in trauma care would clearly be working outside of their scope, which is primary care ONLY

I am not an ER professional, but for FNPs contemplating working in an ER, it would seem wise to consider what the AANP and the American Academy of Emergency NPs have to say on this matter.  I quoted the AANP above.  AAENP:  "It is the position of AAENP that the patient population served by the ENP represents a unique and significantly differentiated set of competencies and behaviors from other APRN population foci. "

https://www.aaenp-natl.org/enps

As explained above, an FNP working in an ER w/o additional certification(s) is going to be in a world of hurt if they are sued for malpractice.  It doesn't matter how many FNPs do this to a plaintiff's counsel.  

[FiremedicMike, RN, EMT-P]

FullGlass said:

A key point is that different states may have different laws and regulations around this, so any FNP who wants to work in an ER needs to be aware of this.

The other key point is that the OP states they want to treat trauma victims.  That is not primary care, it is acute care.  That is very different from what you were talking about.  In that case, I would advise the OP to become a PA, as that is the role better suited for trauma care.  FNPs have NO education or training in true emergency care, and I think trauma care fits into that category.  An FNP working in trauma care would clearly be working outside of their scope, which is primary care ONLY

I am not an ER professional, but for FNPs contemplating working in an ER, it would seem wise to consider what the AANP and the American Academy of Emergency NPs have to say on this matter.  I quoted the AANP above.  AAENP:  "It is the position of AAENP that the patient population served by the ENP represents a unique and significantly differentiated set of competencies and behaviors from other APRN population foci. "

https://www.aaenp-natl.org/enps

As explained above, an FNP working in an ER w/o additional certification(s) is going to be in a world of hurt if they are sued for malpractice.  It doesn't matter how many FNPs do this to a plaintiff's counsel.  

Did you miss my post about going ACNP if they want to be on the trauma team?

[B. Burns]

Most ENPs are family nurse practitioners (FNPs) who obtain additional emergency specialty education either through the completion of an academic or post-graduate fellowship program or through on-the-job training and continuing education (CE). Nurses interested in pursuing ENP preparation and board certification must first obtain certification as an FNP. Then, you can select from a growing number of academic and post-graduate ENP specialty training programs.  AANP Certification Board offers ENP certification