Can NP's perform surgery legally?

Advanced Practice Columnist / Guide · Apr 7, 2014

Few things control what NP's can do:

1. State NP Act - most state NP acts do not go into detail about what NP's can do except for the very basic "Assessment, Diagnosis, and Treatment" of patients they see. Some states, however, may have explicit language that prohibits NP's from doing highly invasive procedures such as surgery.

2. Federal Laws - this is typically a function of CMS, the administrator of Medicare and Medicaid services. Again, no language restricting NP's from performing anything physicians do in fact allows reimbursement of anything performed by NP's that physicians bill for.

3. NP training - skills learned during NP school help in establishing what the NP could do in practice. Performing surgery is not a skill learned in NP school even for ACNP's. Assisting in surgery can be taught, however. In some states, assisting in surgery requires additional RNFA certification on top of NP.

4. Hospital and group practice credentialing and privileging - this would be the biggest roadblock to NP's performing surgery. Hospital and other group medical practice boards are headed by physicians. Anything NP's do in a hospital setting or a group practice has to be approved by a board and surgery is highly protected as an exclusively surgeon role. Again, assisting in surgery is a separate issue and for the most part, are allowed.

Advanced Practice Columnist / Guide · Apr 7, 2014

5. Private health insurance companies - will never empanel NP's to perform surgery in the current climate of training and practice.

Bottomline: if you want to perform surgery, go to medical school and complete a surgical residency program.

allnurses Guide · Apr 8, 2014

Quote
I am a nursing student working on my second degree BSN. I initially wanted to go to PA school but later changed my mind to go ahead and go to nursing school with intent of getting my nurse practitioners license. I have always been intrigued with orthopedic surgery and I know that PAs can perform surgery legally. Vanderbilt states that a nurse practitioner can practice whatever form of medicine that the primary physician practices I was just curious if that included surgery. I read in a couple of the older forums that nurse practitioners can perform surgery but it's very rare but I haven't been able to find any proof of that. Thanks!

Are you talking about working as an assist or a primary surgeon. PAs and NPs can do minor surgical procedure and interventions provided the state practice act supports it. Both can act as first assistant in major surgery. I don't foresee NPs playing any more of a role in major surgery than that (acting as a primary surgeon).

chillnurse, BSN, RN, NP · Apr 9, 2014

if you wanna be a surgeon be a surgeon lol.

jdc6773 · Apr 10, 2014

I appreciate everyone's responses. I was just wondering about surgery because that is the most distinct difference between PA and NP besides the models and viewpoints they are taught in. Thanks again

Advanced Practice Columnist / Guide · Apr 10, 2014

jdc6773 said:
I appreciate everyone's responses. I was just wondering about surgery because that is the most distinct difference between PA and NP besides the models and viewpoints they are taught in. Thanks again

Just want to clarify with you that PA's do not perform surgery like a surgeon would either. You may hear stories of PA's actually cutting and performing part of the surgical procedure but these are performed under the supervision of a surgeon. Citing the 6 determinants of scope of practice I wrote in my previous post (State Law, Federal Law, Training, Credentialing/Privileging, Private Insurance Rules), PA's assist during surgery under the presence of a physician supervisor. There are NP's with similar role.

allnurses Guide · Apr 10, 2014

jdc6773 said:
I appreciate everyone's responses. I was just wondering about surgery because that is the most distinct difference between PA and NP besides the models and viewpoints they are taught in. Thanks again

You are misinformed about that.

MereSanity · Apr 10, 2014

I have worked with MANY NP's that performed surgery with a surgeon (assisting). No need to become an PA....you'd be better off becoming an NP and finding a surgeon to work with.

Big Blondie, ASN, BSN, MSN, APRN · Apr 11, 2014

Surgeons go through an extensive training program. I have credentials for minor procedures and central line, chest tube insertions, but have to have documented formal training and competence assessments during yeary eval. I agree with earlier poster, if you have a dream of being a surgeon, go seek information. Follow your passion.

kbdeleon · Dec 11, 2015

jdc6773 said:
I am a nursing student working on my second degree BSN. I initially wanted to go to PA school but later changed my mind to go ahead and go to nursing school with intent of getting my nurse practitioners license. I have always been intrigued with orthopedic surgery and I know that PAs can perform surgery legally. Vanderbilt states that a nurse practitioner can practice whatever form of medicine that the primary physician practices I was just curious if that included surgery. I read in a couple of the older forums that nurse practitioners can perform surgery but it's very rare but I haven't been able to find any proof of that. Thanks!

This week I witnessed a certified family nurse practitioner do a phlebectomy (vein removal) for a large snaking varicose vein at a vein clinic in a medical center in Texas. The procedure was a procedure requiring repetitive steps and only its sterilization technique as well as final result were observed by the MD. The FNP was assisted during the procedure by an MA who observed the procedure and waited for instructions to be delegated.

Prior to the arrival in the surgical suite of the FNP and the MD, an MA (medical assistant) entered and had the patient change into surgical shorts so that the surgical site could be sterilized later with surgical antimicrobial solution for preparation for surgery.

The Physician (MD) entered the room with the FNP-C and he (the physician) introduced the FNP-C to the patient and said that she (the FNP-C) was going to be taking care of her today.

However the MD did *not* note that the practitioner was an FNP, only that she would be caring for the patient.The MD put on gloves and began removing steristrips (sterile butterfly tape adhesive stitch substitutes) from the previous surgery.

The MA gave instructions to the patient regarding sterile technique not to touch anywhere near the isolated area for surgery once the procedure started.

The FNP put on gloves and prepared medication titrations for the procedure, and asked for the bottles and materials from the MA. The MD examined the prior surgical site to assess it for complications. The physician asked the FNP to see if she saw any abnormalities and she noted that there were no visible details to suggest complications.

After the physician and FNP determined that there were were no complications from the patient's prior surgery, the MD told the patient that the procedure would begin.

The MD observed while the FNP gave the initial local injections and then they left the room together. A CNA (nurse's aid) entered and assisted the MA in prepping the surgical area with orange antimicrobial solution. The FNP entered briefly during this time to pull up information from a computer in the room, apologizing for walking in before the patient was ready (as the surgical suite is small).

The FNP walked out again and after the MA and the CNA both left the room, the FNP entered again with MA. They put on gloves again and the MA took out a surgical kit and opened it. The FNP took out the sterile marker and marked the extremes of the surgical area. The FNP noted to the patient to say if there was any pain at all, to let her know so she can do more injections of local anesthetics. The FNP used scalpel to puncture the vein very slightly in a variety of equally spaced areas about 1 inch between each opening along the length of the varicosed vein. Beginning with the most distal area of the vein, closest to the previous phlebectomy, the FNP used dissection tools to separate the first section of the vein from the surrounding tissue through the initial incision sites, using them as a window through with to manipulate the tools through the incsions immediately adjacent the area of the vein section to be removed. Once the vein section was separated from the surrounding tissue, it was pulled through the nearest incision site using a tool and placed in a collection area. The FNP infused a solution into the surgical area and these procedures regarding the dissection of the vein from the surrounding tissues were repeateded until all of the sections of the vein were removed.

As the FNP was finishing the procedure, the MD entered to observe the FNP completing the procedure. The MD asked if everythinjg was going fine and the FNP responded that it went great and she was almost done. As the FNP pulled out the last vein section, the MD put on gloves and used a liquid solution and sterile gauze to wipe away a small amount of blood that had drained from the incisions as well as remove the sterile marker marks from the surgical area. The MD observed the incisions and the skin above the area the vein was removed from. The MD said that it looked great, and he told the FNP to go ahead close up the incisions. The MD left and the FNP closed up each incision with steri-strips in a butterfly pattern around each encision.

When she was done, she told the patient that the procedure was complete and the MA would put gauze over the surgical site to avoid infection, and then he would put on the compression hose over the gauze and then explain the instructions to the patient.

The FNP left and the MA put gauze over the surgical area and bandaged it in place. The MA put the compression hose over the surgical site, using a paper shoe over the patient's toe and ankle to guide the hose over toenails and around the heel area, all the way past the surgical site.

After this, the MA told the patient that she could change out of her surgical shorts and back into her pants. The patient exited the suite and walked to the follow up appointment desk to make an appointment.

Bluebolt · Dec 13, 2015

kbdeleon said:
This week I witnessed a certified family nurse practitioner do a phlebectomy (vein removal) for a large snaking varicose vein at a vein clinic in a medical center in Texas. The procedure was a procedure requiring repetitive steps and only its sterilization technique as well as final result were observed by the MD. The FNP was assisted during the procedure by an MA who observed the procedure and waited for instructions to be delegated.
Prior to the arrival in the surgical suite of the FNP and the MD, an MA (medical assistant) entered and had the patient change into surgical shorts so that the surgical site could be sterilized later with surgical antimicrobial solution for preparation for surgery.
The Physician (MD) entered the room with the FNP-C and he (the physician) introduced the FNP-C to the patient and said that she (the FNP-C) was going to be taking care of her today.
However the MD did *not* note that the practitioner was an FNP, only that she would be caring for the patient.The MD put on gloves and began removing steristrips (sterile butterfly tape adhesive stitch substitutes) from the previous surgery.
The MA gave instructions to the patient regarding sterile technique not to touch anywhere near the isolated area for surgery once the procedure started.
The FNP put on gloves and prepared medication titrations for the procedure, and asked for the bottles and materials from the MA. The MD examined the prior surgical site to assess it for complications. The physician asked the FNP to see if she saw any abnormalities and she noted that there were no visible details to suggest complications.
After the physician and FNP determined that there were were no complications from the patient's prior surgery, the MD told the patient that the procedure would begin.
The MD observed while the FNP gave the initial local injections and then they left the room together. A CNA (nurse's aid) entered and assisted the MA in prepping the surgical area with orange antimicrobial solution. The FNP entered briefly during this time to pull up information from a computer in the room, apologizing for walking in before the patient was ready (as the surgical suite is small).
The FNP walked out again and after the MA and the CNA both left the room, the FNP entered again with MA. They put on gloves again and the MA took out a surgical kit and opened it. The FNP took out the sterile marker and marked the extremes of the surgical area. The FNP noted to the patient to say if there was any pain at all, to let her know so she can do more injections of local anesthetics. The FNP used scalpel to puncture the vein very slightly in a variety of equally spaced areas about 1 inch between each opening along the length of the varicosed vein. Beginning with the most distal area of the vein, closest to the previous phlebectomy, the FNP used dissection tools to separate the first section of the vein from the surrounding tissue through the initial incision sites, using them as a window through with to manipulate the tools through the incsions immediately adjacent the area of the vein section to be removed. Once the vein section was separated from the surrounding tissue, it was pulled through the nearest incision site using a tool and placed in a collection area. The FNP infused a solution into the surgical area and these procedures regarding the dissection of the vein from the surrounding tissues were repeateded until all of the sections of the vein were removed.
As the FNP was finishing the procedure, the MD entered to observe the FNP completing the procedure. The MD asked if everythinjg was going fine and the FNP responded that it went great and she was almost done. As the FNP pulled out the last vein section, the MD put on gloves and used a liquid solution and sterile gauze to wipe away a small amount of blood that had drained from the incisions as well as remove the sterile marker marks from the surgical area. The MD observed the incisions and the skin above the area the vein was removed from. The MD said that it looked great, and he told the FNP to go ahead close up the incisions. The MD left and the FNP closed up each incision with steri-strips in a butterfly pattern around each encision.
When she was done, she told the patient that the procedure was complete and the MA would put gauze over the surgical site to avoid infection, and then he would put on the compression hose over the gauze and then explain the instructions to the patient.
The FNP left and the MA put gauze over the surgical area and bandaged it in place. The MA put the compression hose over the surgical site, using a paper shoe over the patient's toe and ankle to guide the hose over toenails and around the heel area, all the way past the surgical site.
After this, the MA told the patient that she could change out of her surgical shorts and back into her pants. The patient exited the suite and walked to the follow up appointment desk to make an appointment.

WOW!, you went for the full play by play here.

As for the OP. You would be smart to do an ACNP specialization and then seek out a surgeon needing an NP. Many surgeons have NP/PA's and the stories you hear of PA's doing surgery is like others mentioned under the supervision of the surgeon. A PA can't practice anything at all without the MD's license and presence, so if you want more restrictions on your practice and ability go to PA school instead of NP. You are literally the physicians "assistant" when you obtain your PA.

If you're looking at doing major invasive surgery with general anesthesia etc. then you'll definitely want to go to medical school (4 years), do a 3 year basic residency, then another 2 (I think) in general surgery, then another 2-3 years approximately in the specialty surgery area you're interested in.