In the ED: ACNP vs. FNP

Advanced Practice Columnist / Guide · Feb 14, 2008

I just would like to give my perspective as an Acute Care NP currently working in a critical care setting where we are credentialed to perform invasive stuff such as central lines, chest tube placements, etc. (with the exception of intubations). Although these skills should be part of the training as an ACNP, oftentimes the clinical rotations are not extensive enough to adequately teach these skills to the point of being proficient at it. I have to admit that for the most part, my confidence in performing these skills were built up as I progressed in my current job.

I think the same will hold true for any program that claim to train one to be an NP in an ED setting. Skills take practice to perfect. What you do as an NP student is usually limited by the fact that you are still a student and not an employee. Preceptors may be hesitant to allow you to perform invasive stuff on actual patients for fear of being responsible if something happens. Some programs may not be able to acquire clinical sites that allow students to freely do whatever.

Another factor to consider too is whether the "dream job" you are aspiring for is actually realistic in the area where you live. At times, NP's are trained to do a lot of stuff while in school but once they start their actual job, they find that they are restrained in what they can do by the collabortaive agreement set by the physicians they work with. As an example, I know some NP's working in some of the ED's and urgent care centers here but many tell me that for the most part, they are only seeing urgent care types and no traumas and codes even when they work in the actual ED's.

Having said all these, it is not bad to have a goal and know what you want to do. I think that even if you train in a traditional FNP program you can still learn skills if an ED is willing to hire and train you to perform the advanced skills you wanted to do.

The trend right now is in patient simulation because there are so much risks associated with learning a specific invasive skill. Medical schools have built sim labs for training in invasive procedures. Hospitals in my area have done the same and our own hospital actually have the largest sim lab for surgical, OB, and trauma procedures in the state. I guess what I'm trying to drive at is that you can learn procedures eventually but don't rely entirely on your NP program to teach you everything you need to learn to the point that you can do things autonomously from the get go.

CraigB-RN, MSN, RN · Feb 14, 2008

I am an ED nurse with 15 years experience in ED/ICU that is interested in becoming a Nurse Practitioner with a primary focus of working in a rural ED that would allow me to work as autonomously as the role allows. For NP's that practice in this environment, I have seen both ACNP programs that claim to prepare the student to work in the ED & FNP programs that claim the same. I know that FNP allows you to care for all ages, what are the other differences?
How do FNP grad's of programs that train you to be an Emergency Nurse Practitoner feel about the advanced skills training you received;(e.g, suturing, chest tubes, central lines & such?)
Thank you for taking the time to ponder my post & responding.

having spent 7 recent years of my life as a DON in one of those rural hospitals I'd have to say the FNP even with it's lower acutiy clinical will prob be the safer route to go. In most rural hospitals, you don't have the advantage of only seeing adult patients. About 25% of our ER patients were peds patients. The ACNP would limit you from being able to see those patients in a lot of cases, plus depending on the size of the hospial you will prob need to see clinic also.

The second thing to consider is that only 10% of the ER patients need those specific advanced skills you mentioned. Most are family practice/Internal medicine problems. headaches, flu symptoms etc. Patients that after 15 years as an ER nurse you could probably do most of yourself now.

Since I couldn't decide I"m doing both the ACNP and the FNP, although I'm probably going to change how I'm doing it and do the ACNP as a post grad instead of concurently. But that's just what seems to work for me. My problem with the FNP part is that as a flight nurse, high acuity ICU/ER nurse, i have a hard time getting motivated to read about pelvic floor disfunction in elderly females.

It's better to think of these things now, I didn't and it's making my life harder now. If I had just done one, I'd be almost done now,instead of halfway through.

bodhisattvya · Feb 14, 2008

PinoyNP & CraigB-RN:

Thank you for your responses, I appreciate your insight! PinoyNP, I would like to respond to a portion of your reply:

"Another factor to consider too is whether the "dream job" you are aspiring for is actually realistic in the area where you live. At times, NP's are trained to do a lot of stuff while in school but once they start their actual job, they find that they are restrained in what they can do by the collabortaive agreement set by the physicians they work with. As an example, I know some NP's working in some of the ED's and urgent care centers here but many tell me that for the most part, they are only seeing urgent care types and no traumas and codes even when they work in the actual ED's."

This is the reason why I am willing to relocate to some rural area;(such as remote Alaska) where Nurse Practitioners have the potential to do more. Having my whole worklife based around Fast Track patients sounds like hell to me. PinoyNP, could you tell me more about your job & what it entails? I know that there are ACNP's that function in a Trauma Nurse Practitioner role. I also forgot to mention that I also do have a CCU/ICU background.

CraigB-RN:

The second thing to consider is that only 10% of the ER patients need those specific advanced skills you mentioned. Most are family practice/Internal medicine problems. headaches, flu symptoms etc. Patients that after 15 years as an ER nurse you could probably do most of yourself now.

I understand that the skills I've listed are not the bread & butter of ED Nurse Practitioner work,(with the exception of suturing.) A CRNA once told me that his job was 98% boredom & 2% sheer terror. I consider the ED to be a similar environment. This is not to say that I'm scared of acute presentations, I live for real sick pt's. But I want to feel competent in those lesser-used skills. Your personality & background sounds very similar to mine. Could you tell me more about pursuing both an FNP & ACNP. Are you doing this through the same institution? It appears your from Georgia. I believe that Emory has both of these programs. Is this where you are attending? I appreciate your time regarding this subject.

CraigB-RN, MSN, RN · Feb 14, 2008

I just moved to Atlanta from CO. I've officially dropped the ACNP and am actually doing one of the online programs from a bricks and morter program. It's a #### and I miss the face to face interaction. Emory does have an ER NP program that is both FNP and ACNP, but for me at 50, it's a bit cost prohitative. I'll never recoup hte expense. I"m going to finish the FNP, do the ACNP as a post graduate, and then go on to PhD at my leasure. The PhD is more for me than anythign needed in nursing. I'm planing for the future when my body won't let me handle the back to back 12 hour shift.

The more rural you go, the less real ER your going to be doing. The more rural you go, the greater the chance that you'll be in a clinic position with ER call. Like other posters have said, in the 400-600 hours of clinical your going to get, your not going to get that much "hands on experience" in those skills.

I probably got more experience putting in chest tubes and cenral lines (femeral) as a flight nurse than I was going to get in the ACNP program. Plus I probably did more initial resusitation than most because of the flying time. Why bother with putting in a central line in your septic patient, you won't have the ability to monitor CVP, so if you've got a peripheral line, that's all you need. And fem lines are relativly easy. In that rural environment you can't manage the hemothorax and replace the blood so in most cases you don't NEED to do anything but do a pleural decompresion. Plus the first thing your going to do is scream for the flight crew to take the patient away. Plus in my military life I had 19 yo highschool graduate medics suturing, better than I can

If you are realy set on rural, I'd suggest the FNP, you will need teh pediatric component, try to get some inpatient clinicals as well as ER and if you get lucky ICU. The next time you go to a conference, look for an ultrasound guided lineplacement course, the difficult airway program, or things like that. Start studying now, make sure you've got TNCC, ACLS and all that, plus look into the TNATC course. Audit ATLS if you can. Know those ACS, Stroke, and ACLS protocals well enough that you can spout them in your sleep. You can start working on that now while your waiting for school. Get your CEN and CCRN as well.

There can be a big difference in the fantasy of what you want to do and the reality. I know this for a fact. Been there, done that have the T-Shirt. I hate clinic with a passion, here in Atlanta, NP's in the ER are FNP for the most part.

Of course you could just move to one of the places that has the ERNP programs and get it all done at once. There is the ACNP program in PA that is geared torward critical care transports.

Set yourself up one of those pro's and Con sheets and start looking at what it is your realy want. Talk it over with your family, pray about it, talk to NP's you know, hand out here, go to NP confeence and network. Suck up all the information there is and then make your decision.

Good luck with whatever choice you make. Because of course I could just be an opinionated old man and just blowing smoke. :smokin:

core0 · Feb 15, 2008

i just moved to atlanta from co. i've officially dropped the acnp and am actually doing one of the online programs from a bricks and morter program. it's a #### and i miss the face to face interaction. emory does have an er np program that is both fnp and acnp, but for me at 50, it's a bit cost prohitative. i'll never recoup hte expense. i"m going to finish the fnp, do the acnp as a post graduate, and then go on to phd at my leasure. the phd is more for me than anythign needed in nursing. i'm planing for the future when my body won't let me handle the back to back 12 hour shift.
one point on the emory enp program, its actually an fnp program with 200 hours of em thrown in. here is the program description:
http://nursing.web.emory.edu/nursing/admissions/msn/enpb.shtml
if you are looking for something that will work in a rural area along the lines of what craigb was describing this will probably work. on the other hand depending on the state you are in this will not allow you to work in a main er because the underlying certification is fnp.
snip bunch of good stuff by craigb

another note on the whole rural er thing. i have begun moonlighting at a couple of smaller ers (strangely like craigb i have also moved to atlanta from co). some of these could be described as rural (or at least the outer reaches of suburbia). while most of what i do is primary care or urgent care (sutures, cough, cold etc.). however we do get our fair share of trauma disasters that really shouldn't be gracing our doors. there is an active flight program and most high grade trauma goes right to grady. however, occasionally you do have to do "real" trauma. that means intubating, putting in a chest tube etc. these skills become more important but harder to maintain the more isolated the er is. emedpa who occasionally posts here works in some of these areas. most of the pas his group hires have lots of experience in the er before they solo in a rural er. i told the company that i work for that i only want ers where there is physician back up. for what its worth the company only hires pas because of the age issue for the acnp. personally i feel that solo staffing rural ers should only be done with npps with lots of training in high volume ers.

david carpenter, pa-c

Advanced Practice Columnist / Guide · Feb 16, 2008

PinoyNP & CraigB-RN:
Thank you for your responses, I appreciate your insight! PinoyNP, I would like to respond to a portion of your reply:
"Another factor to consider too is whether the "dream job" you are aspiring for is actually realistic in the area where you live. At times, NP's are trained to do a lot of stuff while in school but once they start their actual job, they find that they are restrained in what they can do by the collabortaive agreement set by the physicians they work with. As an example, I know some NP's working in some of the ED's and urgent care centers here but many tell me that for the most part, they are only seeing urgent care types and no traumas and codes even when they work in the actual ED's."
This is the reason why I am willing to relocate to some rural area;(such as remote Alaska) where Nurse Practitioners have the potential to do more. Having my whole worklife based around Fast Track patients sounds like hell to me. PinoyNP, could you tell me more about your job & what it entails? I know that there are ACNP's that function in a Trauma Nurse Practitioner role. I also forgot to mention that I also do have a CCU/ICU background.

I have described what my job entails in a past post. I couldn't find the link to it so I can give you a short summary here:

I belong to a group of NP's and a PA who staff our hospital's CVICU with a 24/7 coverage along with residents on their ICU and cardiothoracic surgery rotation. There are currently 7 mid-levels and about 2-3 residents who rotate on a bi-monthly basis. We are headed by a group of staff intensivists. We also round with the cardiothoracic surgeons. The hospital is a heart and lung transplant center, obviously with a VAD program as well. In addition, we perform the typical CABG's and valve replacements, aortic aneurysms and dissection repairs. Needless to say, our cardiac surgery patient population tend to be higher risk than the average heart surgery program in most hospitals.

Our responsibilities are typical ICU stuff in addition to post-op recovery of all open heart patients. Because of the nature of the service we are in, we are credentialed to insert Swan-Ganz catheters, all types of centrally inserted catheters, arterial lines, and chest tubes. Incidentally, we are on call for chest tube insertion in the entire hospital except the ER.

Our main hospital where I work at is affiliated with a network of out-patient facilities and 5 other community hospitals. There is a single medical group for the main hospital, no other private physician group have priviledges in the main hospital. All mid-levels are employees of the hospital and are governed by a mid-level council and a mid-level director (currently, a PA).

CraigB mentioned ultrasound-guidance with procedures. Indeed, this is the wave of the future. Our group attended a training program regarding this sponsored by the Society of Critical Care Medicine. We've completely implemented US-guidance with our line placements which has made life easier for both us and the patients. There is still so much application that we can add hopefully as time goes by.

cporter12 · Jan 19, 2009

I absolutely agree. i was/ and still am part time a flight nurse for 10 years then i got my acnp. I wish though that i had gotten my fnp first, then my acnp only because, er where i live tends to be small and rural and therefore sees alot of kids, which i cant see. when i wanted to go back throught the fnp program, it was so full, they were letting the ones who had no degree yet go first, so ive been on a waiting list forever. I want to work er, but have to find one that will not require me to see kids. Anyway, I was not interested in all the fnp stuff either, but now i work as a hospitalist and can see where it would come in handy. I see icu and med/surg pts, and some of them are well enough to be at home, so their care is different than the icu care im used to.

Knowing about all ages though including womens health comes up in internal med as a hospitalist, because you get everything!!

Trauma Columnist · Jan 19, 2009

I'm an adult CNS who works in a community ER. Since I see only those older than 16, I do a lot of gyne stuff. I'm thinking of heading back for the peds CNS in the fall so that I can be more marketable.