FNP working in hospital settings besides ED

Advanced Practice Columnist / Guide · Jul 8, 2012

I feel that your question is similar to this thread, so I'll just post the thread here.

llg, PhD, RN · Jul 8, 2012

Juan wrote a great post in the other thread he referenced above -- definitely worth reading for anyone interested in this topic.

wlaa · Jul 9, 2012

Juan, thanks for your post, it was helpful. When I made the decision to go to FNP school I thought the role was versatile even for hospital settings but I supposed to be safe is to practice within the NP's educational preparation as you mentioned in your post. So for FNP that would be mainly primary care. I also wonder besides the state nursing board rules, don't hospitals also write rules about what NPs can and cannot do? So, if hospital rules say that an FNP can work in critical care and perform such duties, wouldn't that be okay?

CCRNDiva, BSN, RN · Jul 10, 2012

I would not look to a hospital to protect my license. I can't tell you how many time I was given a telemetry RN (I've had to refuse med/surg RNs) to fill a shortage in the ICU while working as an ICU charge RN. I can't tell you how many times we were expected to make due with an inadequate number of RNs for the number of patients we had. It is our responsibility to protect our licenses and careers. The hospital will be the first to hang you out to dry when it comes down to them or you.

I'm not trying to be negative, just trying to provide some insight into how things work within a hospital.

Advanced Practice Columnist / Guide · Jul 10, 2012

Juan, thanks for your post, it was helpful. When I made the decision to go to FNP school I thought the role was versatile even for hospital settings but I supposed to be safe is to practice within the NP's educational preparation as you mentioned in your post. So for FNP that would be mainly primary care. I also wonder besides the state nursing board rules, don't hospitals also write rules about what NPs can and cannot do? So, if hospital rules say that an FNP can work in critical care and perform such duties, wouldn't that be okay?

Like I said in my post, there isn't a single regulation anywhere that states that FNP's and ANP's can not work in a hospital setting and that ACNP's can only work in hospitals. Even the Consensus Model was clear to say that the practice of NP's are not specific to a particular setting. For example, an ANP can work in an Adult Endocrinology clinic-based practice but still round on diabetic patients as a consultant in the hospital and provide recommendations on glucose management for those patients. Similarly, nothing is stopping an ACNP who works for an Adult Cardiology service in following up patients known to the service in the clinic once the patient is discharged from the hospital.

Individual hospitals do write rules about what NP's can and can not do within the confines of the hospital campus. This is what credentialing and privileging is all about. Privileging, in short, allows the NP to provide care in the hospital setting as a non-physician provider capable of performing general hospital-based roles such as admission, writing orders, rounding daily, and discharging patients. These are things most hospital providers do regardless of specialty. Credentialing allows the NP to perform specialty-based procedures (i.e., bone marrow biopsies, central line insertions, lumbar punctures, bronchoscopies).

You mentioned critical care practice as an FNP. I'll be honest to say that you will see that this is happening in some places. There are reasons why you see this. One, the ACNP educational path is relatively new. There have been nurse practitioners working in ICU's before ACNP programs became widely available. Two, there is a national shortage of intensivists such that non-physician providers have been recruited to ICU roles to supplement ICU provider staffing. Unfortunately, physicians and hospitals, the entities responsible for recruiting NP's, can be unfamiliar with the risks involved when a provider's training is not suited for the particular specialty.

When a nurse practitioner applies for privileges and credentialing at a particular hospital, he or she volunteers personal information about educational background, training, and special skills to the hospital entity, typically, the Medical Affairs board. You attest to the fact that to the best of your knowledge, you are trained adequately for the role and the accompanying requirements of the specialty you are requesting privileges and credentials to. It is not a one sided deal where the hospital sees you fit and you are good to go. You as a professional, holds the responsibility to be truthful about your educational preparation and how well you fit in the role you are seeking.

If you look at it from a risk management perspective, would you be able to defend yourself should a situation arise when an adverse event occurs under your watch? True, in most cases the hospital malpractice policy will cover your legal responsibilities and sure, the elements of negligence should be present for a case to be substantiated. But worst case scenarios should never be ignored. Wouldn't it be possible that the hospital could wash their hands off an unfortunate mistake by saying that the provider misrepresented themselves as educationally prepared for the role and point a finger in your direction instead?

Many nurses invoke years of experience as critical care nurses at the bedside as the basis for competence in critical care even though their training as an NP is not in acute care. I will defer my answer to an article published in the literature about the topic. Kleinpell and her colleagues in a publication in the Nursing Administration Quarterly states, "In the acute care hospital setting, it becomes especially important that nursing administrators have a clear understanding of the scope of practice of the APRNs seeking credentialing and privileging. APRNs requesting credentialing and privileging for acute care skills require proper educational preparation and training and the requisite skills to be practicing within their scope of practice".

The article goes on further to say, "APRNs who might have been educationally prepared as an adult nurse practitioner or a family nurse practitioner who are hired to work in an acute care setting may need post–master’s acute care nurse practitioner education to ensure they are practicing within their scope of practice. For APRNs practicing in the acute care setting who are not trained for acute care practice, seeking credentials and privileging must be in compliance with their education and training as an APRN. Prior nursing experience in a specialty area, such as critical care or acute care, does not entitle APRNs to seek credentials and privileges for acute care practice if their APRN education and training is not acute care focused".

See:

http://www.mc.vanderbilt.edu/documents/CAPNAH/files/Developing an APN credentialing modelfor acute care facilities.pdf

BlueDevil,DNP, DNP, RN · Jul 10, 2012

FNPs function in all capacities here, inpatient and outpatient. ACNPs are very rare, even at the University hospital.