ANP vs. FNP for cardiology?

ANPFNPGNP · Jun 1, 2008

I live in TX and I completed a post-Master's FNP program at UT-Houston. Our professors told us that FNP's could NOT work in the hospital in Texas. However, we CAN work in the ER-Fast Track. However, we were told that Adult NP's who had an acute care rotation in their program (we did 90 hrs in AC at Vandy) were able to work in the hospital, but not the ICU. The TX BON is supposed to come out with a newsletter in either late summer/early Fall addressing this very topic.

When I attended UT-Houston, we were told that 17 FNP's were fired from TX Children's Hospital b/c the BON found out they were working in the hospital. FNP's are trained to work in PRIMARY CARE ONLY!

djc1981 · Jun 1, 2008

I live in TX and I completed a post-Master's FNP program at UT-Houston. Our professors told us that FNP's could NOT work in the hospital in Texas. However, we CAN work in the ER-Fast Track. However, we were told that Adult NP's who had an acute care rotation in their program (we did 90 hrs in AC at Vandy) were able to work in the hospital, but not the ICU. The TX BON is supposed to come out with a newsletter in either late summer/early Fall addressing this very topic.
When I attended UT-Houston, we were told that 17 FNP's were fired from TX Children's Hospital b/c the BON found out they were working in the hospital. FNP's are trained to work in PRIMARY CARE ONLY!

This is not true. It is region-dependent. Where I live, nearly all NPs working in the hospital in all areas are FNPs. It just depends on what programs are available in your area and the need, as well as each state's BON. If the hospitals here fired all the FNP's, they wouldn't have any NPs left!

Angie O'Plasty · Jun 1, 2008

Wow, talk about an old thread! I ended up going for ACNP and just have one more year before I finish.

core0 · Jun 2, 2008

This is not true. It is region-dependent. Where I live, nearly all NPs working in the hospital in all areas are FNPs. It just depends on what programs are available in your area and the need, as well as each state's BON. If the hospitals here fired all the FNP's, they wouldn't have any NPs left!

This is very region dependent. It depends on how closely the BON adheres to its own rules. It also depends on other outside factors. There are essentially three entities that can limit scope of practice. The state can do this either through the regulatory process or new interpretation of current regulations. Insurance companies can limit scope through reimbursement. Hospitals can limit scope through credentialing.

In my previous practice most of the cardiology NPs were FNPs. However, while the hospitals would continue to credential them, they refused to credential new FNPs for inpatient services. What changed? The advent of the ACNP in the market. This seems to be mostly driven by insurance claims that were mentioned above. Frustratingly it all seems to be anecdotal. There is no case law that anyone that I know can point to. All of the cases that I am aware of have been settled out of court. Also interestingly the reason that I was told they were settled was not because the NPs insurance refused to cover because of scope. Instead both of these were settled because the NP was ruled out of scope which opened the hospital up to malpractice claims that were outside of the med-mal limitations but also exposed the hospital to claims of insufficient credentialing.

If you stay within your scope as defined by didactic and clinical training as an NP there should be no issue (in my non-np opinion). Outside of this there will continue to be regional variation. However, you continually have the danger of restriction to your scope of practice with no warning. The chance that this will happen depends on how active your BON is and how remote your practice is (in my experience). YMMV.

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Jun 2, 2008

If you stay within your scope as defined by didactic and clinical training as an NP there should be no issue (in my non-np opinion). Outside of this there will continue to be regional variation. However, you continually have the danger of restriction to your scope of practice with no warning. The chance that this will happen depends on how active your BON is and how remote your practice is (in my experience).

I totally agree (in my NP opinion)!

ANPFNPGNP · Jun 2, 2008

This is not true. It is region-dependent. Where I live, nearly all NPs working in the hospital in all areas are FNPs. It just depends on what programs are available in your area and the need, as well as each state's BON. If the hospitals here fired all the FNP's, they wouldn't have any NPs left!

It is very possible that the hospitals in your area aren't aware of any of this. As I mentioned, Texas Children's Hospital (a very prestigious hospital) was forced to fire 17 FNP's, because the TXBON informed them that all of those NP's were practicing outside their scope. That only happened a little over a year ago.

I graduated with a FNP certification from UT-Houston (one of the top NP's programs in the nation) and we did not have any classes nor clinicals pertaining to inpatients. FNP's are trained to work in primary care only and everything else is considered outside our scope. The fact is, if a FNP can do it all, then why in the heck even have ACNP's in the first place? There is a reason for all those different NP specialties. There is no such thing as a "generalized" NP!

BTW, the hospitals in your area are taking a huge risk having FNP's seeing patients. Lawyers will be all over this in the case of a malpractice lawsuit involving a hospitalized patient. This isn't a "regional" thing at all, it has everything to do with our scope of practice as determined by the AANP and ANCC. Also, how are those FNP's getting recertified every 5 years? We have to practice 1,000 hrs IN OUR SPECIALTY every 5 years in order to recertify. The ANCC does random audits and the AANP requires that we list the places we've worked and the types of patients we've seen. As a FNP, I have to "prove" that I have seen patients of all ages in a primary care setting.

Advanced Practice Columnist / Guide · Jun 3, 2008

FNP's are trained to work in primary care only and everything else is considered outside our scope. The fact is, if a FNP can do it all, then why in the heck even have ACNP's in the first place? There is a reason for all those different NP specialties. There is no such thing as a "generalized" NP!
BTW, the hospitals in your area are taking a huge risk having FNP's seeing patients. Lawyers will be all over this in the case of a malpractice lawsuit involving a hospitalized patient. This isn't a "regional" thing at all, it has everything to do with our scope of practice as determined by the AANP and ANCC. Also, how are those FNP's getting recertified every 5 years? We have to practice 1,000 hrs IN OUR SPECIALTY every 5 years in order to recertify. The ANCC does random audits and the AANP requires that we list the places we've worked and the types of patients we've seen. As a FNP, I have to "prove" that I have seen patients of all ages in a primary care setting.

These are very good points to consider when choosing an NP program. I live in a state where there are no set scope of practice for NP's of different specializations. Here, you see FNP's cross over to in-patient positions in hospitals a lot. But just because the hospitals and the BON have remained ignorant of the specific differences betwen NP specializations, makes it OK for any NP to practice out of the scope of his or her training and certification.

In cases of legal actions against an NP provider, questions asked during a deposition involve verifying the NP's qualifications - what was the didactic content of the NP program, what clinical rotations were completed, what certification was taken including what competencies were tested in the certification. It's not enough to say that you have practiced as an RN for many years in the in-patient setting. Many RN's have the same clinical experience but that by itself did not grant the NP the authority to practice at an advanced level. It's the NP's educational training and certification that determined that the provider is qualified to practice within their scope.

If one is after a mid-level role that can cross multiple settings and age groups, I personally advice others to pursue the PA-C route. One's scope as a PA is determined by the scope of the supervising physician, no further questions asked.

ANPFNPGNP · Jun 4, 2008

The TXBON states that our scope of practice is determined by the certifying bodies - for FNP's, those certifying bodies are the AANP and ANCC. I'm 99.9% sure that every state's BON has the same requirements. Anyone can go online and read the scope of practice for FNP's on the AANP or ANCC websites. It clearly states that we see patients across the lifespan in a primary care setting!

If a FNP chooses to practice in a hospital setting, then they need to realize that it will all come tumbling down when there's a malpractice claim filed against them. It's pretty sad when the malpractice attorney's know more about the various "scopes of practice" than the NP's do- UNBELIEVABLE! :imbar

djc1981 · Jun 4, 2008

don't shoot the messenger -- i'm just stating how it is here. the realities are different for everywhere. my state has no acnp program, and all job ads just state they want a np. i'm sure its much different in larger cities and metropolitan areas. this is just the reality of the situation and need here. ok --- implode away.

7starbuck7 · Jun 4, 2008

The thing that confuses me about this...Family Practice MDs admit to the hospital and see their own patients. They have their own in-patient floor in the hospital. Could their FNPs not see those paitents? Confusing.

ANPFNPGNP · Jun 4, 2008

Family practice doctors are "generalized" practitioners and FNP's aren't. The majority of FNP programs only require 500 clinical hours and they can barely cover primary care issues during those few hours. That's why there is a push for the Doctorate in clinical practice, because then there would be training comparable to family practice doctors.

Frankly, I can't imagine having just gone the FNP route without doing the ANP/GNP first (especially the geriatric specialty). I only had to complete 800 clinical hours for that dual degree and I felt that wasn't enough - that was with over 8 years of nursing experience. When I went back for the FNP, I had to complete an additional 500 clinical hours (it didn't matter that I was already certified as an ANP/GNP) and I used a lot of those hours to precept with an internist who only sees highly complex patients. With the aging of America, there needs to be an intense focus on elderly patients and the FNP programs definitely aren't requiring enough didactic nor clinical hours in that area. Basically, FNP's aren't even getting enough training in PRIMARY CARE.

ANPFNPGNP · Jun 4, 2008

In cases of legal actions against an NP provider, questions asked during a deposition involve verifying the NP's qualifications - what was the didactic content of the NP program, what clinical rotations were completed, what certification was taken including what competencies were tested in the certification. It's not enough to say that you have practiced as an RN for many years in the in-patient setting. Many RN's have the same clinical experience but that by itself did not grant the NP the authority to practice at an advanced level. It's the NP's educational training and certification that determined that the provider is qualified to practice within their scope.
If one is after a mid-level role that can cross multiple settings and age groups, I personally advice others to pursue the PA-C route. One's scope as a PA is determined by the scope of the supervising physician, no further questions asked.

YOU ARE 100% CORRECT! I know of several cases where FNP's have lost lawsuits (and gotten disciplined by the BON) because they were practicing in areas they weren't trained/certified. As you mentioned, it doesn't matter that they have practiced as a RN for multiple years in the hospital, if they aren't certified as an ACNP, then they have no business practicing as one. This would be comparable to a family practice doctor specializing in cardiology, nephrology, etc. That would be a malpractice attorney's dream!