Clinicas in ED for FNP programs....Mine doesn't

ECMOismygame · Dec 19, 2007

Hey there everybody.
I am in a nurse practitioner program (FNP track). A few years ago, in this program, students were allowed to do some clinicals in the ED. Now, they won't let us do clinicals in the emergency room, as they say the FNP program is for practitioners that are going to be working in family practice settings. I understand this, hence FNP, but on the same token, our local emergency departments need practitioners, they don't want to hire ACNP, because the populations they treat are more specific (adults). Still, the group that hires practitioners where I work says that if they hire practitioners, they'd like them to have done some clinicals in the ED. I plan on working in a MD's office when I graduate, but I'd like the option of working in the ED at some point. That's where I work now, and I would miss it. I thought about the ACNP track, but it's not offered close to where I work or live, and now I'm already a semester into this. Anyway, do you think after some time in an office a staffing group would hire me to do some ER work? Also, it it possible one of these groups offers a training program for FNPs to get acquainted with ER work. You would think all of my ER training (5 years by the time I graduate, only place I've ever worked) would help somewhat. I don't know. Anyway, thanks for reading. What do you all think.

only a prePA here, but from ive seen and read you could start in fast track then move into the main ED after gaining experience.

core0 · Dec 20, 2007

Hey there everybody.
I am in a nurse practitioner program (FNP track). A few years ago, in this program, students were allowed to do some clinicals in the ED. Now, they won't let us do clinicals in the emergency room, as they say the FNP program is for practitioners that are going to be working in family practice settings. I understand this, hence FNP, but on the same token, our local emergency departments need practitioners, they don't want to hire ACNP, because the populations they treat are more specific (adults). Still, the group that hires practitioners where I work says that if they hire practitioners, they'd like them to have done some clinicals in the ED. I plan on working in a MD's office when I graduate, but I'd like the option of working in the ED at some point. That's where I work now, and I would miss it. I thought about the ACNP track, but it's not offered close to where I work or live, and now I'm already a semester into this. Anyway, do you think after some time in an office a staffing group would hire me to do some ER work? Also, it it possible one of these groups offers a training program for FNPs to get acquainted with ER work. You would think all of my ER training (5 years by the time I graduate, only place I've ever worked) would help somewhat. I don't know. Anyway, thanks for reading. What do you all think.

There are a couple of post on this here if you look. There are ENP programs that are either FNP/ACNP programs or FNP programs with additional training in the ER. If you look at this thread:

https://allnurses.com/forums/f34/once-i-earn-fnp-should-i-go-acnp-too-pros-vs-cons-268417.html

Specifically PinoyNP's post. If you substitute ER for ICU/Hospitalist you are looking at the same issues. The problem with scope in the ER is that it is very dynamic. You could easily argue that episodic urgent care (ie fast track) is well within the domain and scope of the FNP. However lets say you find yourself intubating, putting in a chest tube, a central line and running pressors on a patient. This is very much not within the scope of an FNP. It would however be in the scope of the ACNP.

Most state boards hold that if it not specifically within the scope of one domain and is in the scope of another then only that domain can cover the given scope.

The same rules apply to pediatrics. If you use the FNP to access pediatrics then you could easily find yourself outside the scope of the FNP depending on the acuity and illness of the patient.

The real solution will probably the development of a true ENP program and certification. I was at a talk by a fairly well know NP educator who stated that the only nurse who was competent to see all patients in the ER was an ACPNP/ACNP. I was sitting right behind the local director of the ENP program (FP + ER hours). Given the glare I am surprised the podium did not burst into flames;).

David Carpenter, PA-C

ruralnurs · Dec 20, 2007

core0 stated:

"However lets say you find yourself intubating, putting in a chest tube, a central line and running pressors on a patient. This is very much not within the scope of an FNP. It would however be in the scope of the ACNP.

Most state boards hold that if it not specifically within the scope of one domain and is in the scope of another then only that domain can cover the given scope.

The same rules apply to pediatrics. If you use the FNP to access pediatrics then you could easily find yourself outside the scope of the FNP depending on the acuity and illness of the patient. "

This is not the case here in Montana. I specifically contacted my SBON because I was offered a job as a nurse practitioner in a community mental health center. I was told that a Family Nurse Practitioner has a VERY broad scope of practice, probably the broadest. They can care for people from birth to death and are like a Family Practice MD in that they can and do care for people with psych issues, the elderly, pediatrics work in EDs (where I work we have only Family Practice MDs in the ED), hospitalist, and obstetrics as wel as other areas. The exception (atleast here) is that while an FNP can do all prenatal exams, s/he can't deliver babies.

I did some of my clinicals with an FNP that came to MT from FL and was a specialist in pediatrics, that is all she did. I know an FNP that works with and specializes in neurology. I have been offered the position in my little hospital as hospitalist. I am not taking it as I have little kids and the job is 7 days on and 7 days off with 48 hour strait call on weekends. Currently an MD holds that position.

It is within the scope of practice for an FNP to do pressors, chest tubes and central lines, at least according to Montana SBON. I would check before I discounted being able to hold that position.

As for the original question as to why FNP programs don't allow or encourage ED preceptorships...I think it is just like in nursing school. We are expected to get a good solid med/surg background first and then specialize if that is the desire. If all you did as an FNP student was ED, then when you were expected to care for "normals" or even simple things like PAPs, sports physicals, diabetic med adjustment, you would been in unfamiliar territory. Also even the charting is different, in the ED it is much more quick and in primary care there is more detail needed.

You can always specialize later. I would think that any facility that employs NPs would love to have a FNP with significant ED experience. You would be great in the true emergent patient, but also be comfortable with the patients that seem to think the ED IS thier primary care provider!

core0 · Dec 20, 2007

This is not the case here in Montana. I specifically contacted my SBON because I was offered a job as a nurse practitioner in a community mental health center. I was told that a Family Nurse Practitioner has a VERY broad scope of practice, probably the broadest. They can care for people from birth to death and are like a Family Practice MD in that they can and do care for people with psych issues, the elderly, pediatrics work in EDs (where I work we have only Family Practice MDs in the ED), hospitalist, and obstetrics as wel as other areas. The exception (atleast here) is that while an FNP can do all prenatal exams, s/he can't deliver babies.
I did some of my clinicals with an FNP that came to MT from FL and was a specialist in pediatrics, that is all she did. I know an FNP that works with and specializes in neurology. I have been offered the position in my little hospital as hospitalist. I am not taking it as I have little kids and the job is 7 days on and 7 days off with 48 hour strait call on weekends. Currently an MD holds that position.
It is within the scope of practice for an FNP to do pressors, chest tubes and central lines, at least according to Montana SBON. I would check before I discounted being able to hold that position.

I would suggest you read PinoyNPs post if you haven't. Specifically it dealt with the same issue. Some state BONs will state you are within your scope but your job is essentially at risk if the BON changes their mind. In general I have found that credentialling and scope is not as much a concern in rural areas as it is in urban areas. You may be just fine.

The other issue you have to consider is your liability. There is at least one NP in a neighboring state that has stated in writing that what you are doing is outside your scope. This puts you potentially in a precarious situation (for the record you could easily find a physician to testify that ER work is outside the scope for a FP physician if you wanted to and there is an ABEM statement that only BC/BE EM physicians should work in the ER).

I also note that Montana is not a compact state so most compact rules apply. Implicit in joining the compact is that the scope is the same in all of the compact states. Most of the compact states are following Texas' lead and using the nursing matrix that states you must have training in the domain that you are working. You provided an example of an FNP that only did pediatrics. I can show you anecdotal examples of FNPs that were suddenly unemployed when a different state BON stated they were outside their scope doing pediatric inpatient medicine. YMMV.

Just as PinoyNP stated. If you are working in the hinterlands it will probably never be a problem. If you are working in a more urban environment or a stricter state such as Texas it may be a problem.

David Carpenter, PA-C

ruralnurs · Dec 20, 2007

You are probably right in that much of what happens in Montana is due to the fact that we are very rural (actually frontier in many places). I know NPs that do not have master's degrees, just certificates in certain specialties (women's health, nurse midwife and psych) and were grandfathered in a few years ago when Montana wanted all NPs to be master's prepared.

If they went on to state that NPs need to have speciality certification they would probably grandfather in many that were working in speciality areas.

It probably helps that most docs here are more "nurse practitioner friendly" than in many states, and we have full prescriptatory rights (of even controlled drugs), do not have to practice with or under an MD and can own our practice with only 10% of our charts audited by another NP. Sounds good but we are not paid real well.

kyboyrn · Dec 21, 2007

Okay guys. Thanks for the input. Still, in my er, no NPs, ACNP or otherwise intubate or put in chest tubes. Absolutely under no circumstances. Where we work, we have a doctor, 2 for most of the day, and one mid-level (PA or NP). The mid-level always has a doctor or two by their side, and they don't see the critical patients. So that's not an issue. Also, the nps kind of decide which patients they want to see, and the MD's see the more acute patients. If something an NP/PA sees turns into something that is not within their scope of practice, or more than what they're comfortable with, they often endorse the patient to the MD, or at least have him available for consultation. That's why I can't understand why they won't just hire an FNP, and train them there. Oh well, I'll see when I get to that point. I think I would miss the old ER, but if I have to work in an office exclusively, i guess I could. Thanks for the responses.