Inpatient Certification Requirements By State

Advanced Practice Columnist / Guide · Jul 8, 2012

nothing's crystal clear in the nursing world, if you don't already know that. board of nursing language across all states are very broad and general with many not even addressing the fact that there are multiple specialty tracks to clinical practice as an np. there isn't a regulation anywhere that states that fnp's can not work in hospitals and acnp's can not work in the clinic. there is no regulation that states that np's can not practice in the home care setting either. however, there are a few states that scrutinizes each np's specialty preparattion (i.e., fnp, anp, and so forth) more closely and applies this specialty preparation in determining the scope of practice for a particular np certified in that state.

for example, the texas board of nursing states, "formal advanced practice nursing education is the foundation for the individual's scope of practice and evolves over the professional lifetime of the individual. clinical experience in various settings, continuing education, formal course work and developments in healthcare all impact individual scope of practice. however, there are finite limits to expansion of scope of practice without completing additional formal education. advanced practice nurses cannot change their legally recognized titles or designations through experience or continuing education; these changes may only be achieved through additional formal educational preparation and meeting all legal requirements to use that title and practice in that specialty set forth by the bon". see: apn scope of practice

are you in maryland right now? i made that assumption based on your user name (jhu?). maryland also seems to have stricter guidelines on np specialty preparation. recently, that state required np's to apply for attestation prior to starting practice. attestation basically gives the np the practice privileges but it also includes specific procedures the np could do that is not part of the general roles np's do in that state. the information for individual np attestations are online in their website. if you look closely in that site, only those with acnp credentials have attestations that allow them to do critical care-based procedures (central lines, arterial lines, lumbar punctures). see:http://www.mbon.org/main.php?v=norm&p=0&c=adv_prac/attestation_review.html

lastly, arizona (an independent np clinical practice state), in an advisory opinion, used language that implies specialty-specific roles for nurse practitioners. the board states, "a nurse practitioner shall only provide health care services within the nurse practitioner's scope of practice for which the rnp is educationally prepared and for which competency has been established and maintained. educational preparation means academic coursework or continuing education activities that include both theory and supervised clinical practice". see: http://www.azbn.gov/documents/advisory_opinion/ao nurse practitioner description of role and functions rev jan 2009.pdf

i do agree that the statements i quoted above, though a bit more specific than the general language in most bon's, still do not clearly define boundaries. as we move forward in advanced practice, i think more and more states will look into the "consensus model of aprn regulation" - the new catch phrase in the apn world. the consensus model states that the practice of cnp's (the actual letters they want np's to use) is not restricted by setting. however, the model does state that there are separate competencies for acute and primary care based specialties and that they are not interchangeable. see:http://www.aacn.nche.edu/education-resources/aprnreport.pdf.

there is a push to make the consensus model the national standard for licensure, accreditation, regulation, and education for all apn's on a grand scale. many if not all national np certification boards seem to have made changes in their certification programs to reflect the language in the consensus model. the national council that represents the state boards (ncsbn) is involved in this actively as well. in fact, their website have a map of which states have jumped on board and which ones are in the development phase of implementing it. see: https://www.ncsbn.org/aprn.htm

so to answer your question, because i'm sure you're still scratching your head as i am, i feel that the best way for a nurse practitioner professionally, legally, with risk management in mind as we must always do, and barring the lack of regulatory language in most state bon's, we should be smart to practice within our educational preparation regardless of where we are in the us. we are responsible for safeguarding our license and certification by making sure patient safety is of utmost importance. in the end, the question will be how well prepared are we in doing the acts we do as nurse practitioners.

llg, PhD, RN · Jul 8, 2012

Great post, Juan. The current situation in graduate education for nurses wishing to practice in in-patient settings is confusing -- and I believe not getting enough attention from our educational leaders, who seem to be more focused on the outpatient NP role. I know lots of people who want to practice in a variety of roles within a hospital setting who can't find a good educational program fit. Thank you for helping to clarify some of the issues for our allnurses colleagues.

JHU_BlueJay · Jul 8, 2012

Juan,

Thank you for the information, I really do appreciate it. This is along the lines of what I was already thinking but felt like I couldn't get confirmation from anyone (or anything).

I'm probably going to pick up my acute care certificate anyway. It's only two more semesters for me part time.

bsnanat2 · Jul 8, 2012

I agree with Juan, but would like to caution APRN's from getting into a turf war with one another. While I don't feel that the average FNP should be in ICU, I don't think it wise for ACNP's to go "gunning" for them either. Outside of the ICU and Trauma ER, FNP & certainly ANP can easily handle these things. Most hospitalist type positions are nothing more than inpatient primary care. We already have the RNFA skills that any NP can pick up if they want to work in surgery and ACNP's (in my opinion) should be able to work in any specialty office they choose. The best option is to get both certs, which is not a bad idea for everyone. The tradeoff for more the little bit more of independence that APRN's get over PA's is the possibility of greater restriction in practice areas. We need to be smart and not make problems for one another by either crying "foul" when someone takes a position we think they shouldn't or by taking a job we are not qualified for. We are professionals and one of the tenets of professionalism is knowing your limits. I look forward to the day when we teach primary care and acute care as a matter of course in all programs.

CCRNDiva, BSN, RN · Jul 10, 2012

Juan, thank you so much for taking the time to research the information you posted. I think your advice is well warranted. Unfortunately, we live in a litigious society where we have to be careful not to put our careers at risk. The healthcare arena is becoming increasingly specialized, even physicians are required to obtain additional training to enter additional specialties.

core0 · Jul 10, 2012

Juan made a great post. I can add a little bit. Colorado does not currently require a certain certification to do a job, however, many of the hospitals require ACNP for inpatient work. Pennsylvania is similar (or was five years ago). The farther you get from a large city the looser the requirements get. Most hospitals in a major city require the physicians to become board certified within three years or lose privileges. In outlying hospitals all they look for is a medical license.

Another thing Juan pointed out in another post is liability. In the south a number of lawyers have made a practice of using scope of practice with NPs to get out of med mal limits. In respect to Pennsylvania its easily one of the most litigious areas in the country. Don't count on the fact that the nursing board doesn't have a position to save you there.

As far as ANP in the hospital thats a tough question to answer. A lot of places are going to look at your training. If you have inpatient experience then it will help. If all of your training is in outpatient ambulatory medicine then its not.

As far as the comment that hospitalist is inpatient primary care, that must be a different hospital than where I'm at. We move very sick people out of the ICU all the time and very sick people never come to the ICU. All of our hospitalist NPs are ACNP.

Advanced Practice Columnist / Guide · Jul 11, 2012

i agree that the hospitalists role is more complex than the statement that "most hospitalist type positions are nothing more than inpatient primary care". in fact the hospitalists at my institution will likely take offense if i said that. but it could be true in smaller community settings, i suppose. what is interesting is that there are two-year fellowships in hospital medicine for physicians now (granted it is focused on the academic hospitalist role). see:

ucsf department of medicine | | hospital medicine fellowship

core0 · Jul 11, 2012

i agree that the hospitalists role is more complex than the statement that "most hospitalist type positions are nothing more than inpatient primary care". in fact the hospitalists at my institution will likely take offense if i said that. but it could be true in smaller community settings, i suppose. what is interesting is that there are two-year fellowships in hospital medicine for physicians now (granted it is focused on the academic hospitalist role). see:
ucsf department of medicine | | hospital medicine fellowship

there are actually quite a few

hospitalist fellowship programs | society of hospital medicine

they generally fall into two tracks. im is for academics has minimal clinical time with a lot of research. its also used for people trying to bulk up their application for more competitive specialties (in lieu of a chief year).

for fp it represents the lack of inpatient experience in newer programs that emphasize outpatient ambulatory medicine. the general consensus is that fp doesn't have enough icu or floor time to be competent at inpatient medicine.

peds is kind of mixture. more floor time than im but more research than fp.