FNP doing procedures - page 2

I'm interested in the midlevel provider role in healthcare so obviously I'm examing the PA and NP professions with FNP being the part of advanced practice nursing that interests me. Out of... Read More

  1. by   nomadcrna
    Yes to all you asked.
    suturing is pretty basic. I'm not sure how you can even do clinic without this skill.
    Casting, splint, joint injections, aspirations, I&D, minor office surgeries, xray interpretation are all skills you need in the clinic.
    I don't do endoscopies but there is an FNP in the large city near where I am that does a fantastic job. She was taught at that hospital.

    If you solo ER, you need to be proficient in intubations, chest tubes, central lines, trauma resuscitation etc.
    You do not need a physician, period. At least in the states that I choose to work.

    As others have said, much depends on the state and facility credentialing. Facilities can be tough. I always work to change the bylaws to be NP friendly.

    Where I currently practice. NPs are full members of the med staff. We admit and manage our own patients. It is a great practice.

    You just need to figure out a way to get the education and training. There are intensive courses but the best way is to have a mentor who can teach you and lots of opportunities to practice.
    If you have an OR, talk to the CRNA. I was always happy to teach NPs to intubate and let them practice.

    Quote from ArkansasFan
    I'm interested in the midlevel provider role in healthcare so obviously I'm examing the PA and NP professions with FNP being the part of advanced practice nursing that interests me. Out of curiosity, and I know things differ between states, what procedures do FNPs practice in comparison to PA or phyisicians. For example, it seems I've seen some skepticism in FNPs suturing patients, etc. Do they do that, cast, splint, joint injections, aspirations, debriedments, endoscopies, etc.? If they work in emergency departments, in say more rural areas, would they be doing chest tubes, intuabations, and so forth if the need be alongside a physician or perhaps in place of one? Finally, I've looked at the curriculum for FNP programs at many universities, and I wonder where the training to interpret x-rays and other imaging diagnostics may come from particularly since there is no gross anatomy component to FNP programs. I'm aware of the different "models" used to train nurses and PAs, but I haven't exactly seen a listing of what FNPs may be doing other than "ordering and interpreting tests, diagnosing and prescribing."

    Lots of questions there, I know. Hoping some of you may can answer them. Thanks!!
  2. by   nomadcrna
    First I've heard of NP organizations encouraging state boards to limit FNP practice. Do you have link or article to back this up?
    More states allow full practice as long as you can back it up with education or training.
    Rural areas have a great need and FNPs full a role. Part of primary care IS admitting and managing your patients.
    Most rural hospitals WANT the FNP to be well rounded and able to "do it all".

    Quote from UVA Grad Nursing
    The training, role and practice of Family Nurse practitioners is grounded in primary care. The national NP organizations are encouraging State Boards of Nursing to limit the practice of FNPs to primary care settings, and more employers are encouraging their present staff with FNP certification working in inpatient areas or specialty clinics to go back to school and obtain ACNP certifications.

    If the OPs true love is the procedural arena, then a FNP program may not be the best choice.
    Last edit by nomadcrna on Mar 16, '12
  3. by   nomadcrna
    American Academy of Nurse Practitioners
    Nurse Practitioners in
    Primary Care
    Administration
    P.O. Box 12846
    Austin, TX 78711
    P 512.442.4262
    F 512 442.6469
    Office of Health Policy
    P.O. Box 40130
    Washington, DC
    20016
    P 202.966.6414
    F 202.966.2856
    With 89% of the nurse practitioner (NP) population prepared in primary care and over 75% of
    actively practicing NPs providing primary care, NPs are a vital part of the U.S. primary care
    workforce. Evidence supports the high quality and cost-effectiveness of NP care and the continued
    interest of the discipline to contribute to solving the primary care dilemma.
    Ninety percent of the 140,000 NPs credentialed
    to practice in the U.S. are actively practicing.
    Fulfilling the potential of the Affordable Care Act
    (ACA) requires transformation of primary care
    delivery within the U.S. NPs are a vital element
    of the primary care workforce with a major role
    in making high-quality, patient-centered health
    care available to the broadest possible range of
    consumers. In fact, NPs make up the most
    rapidly growing component of the primary care
    workforce. As licensed independent providers
    prepared with a blend of medical and nursing
    preparation, NPs are uniquely prepared and
    qualified to provide the patient-centered care
    that is central to meeting the existing and future
    primary care needs of our nation.
    NP Scope of Practice and Preparation
    The NP scope of practice includes blending
    nursing and medical services for individuals,
    families, and groups. NPs diagnose and manage
    acute and chronic conditions and emphasize
    health promotion and disease prevention. Their
    services include, but are not limited to ordering,
    conducting, and interpreting diagnostic and
    laboratory tests; prescribing pharmacologic
    agents and non-pharmacologic therapies; and
    teaching and counseling. They practice
    autonomously and in collaboration with other
    healthcare professionals to manage patients’
    health needs.
    NPs are prepared through academic graduate
    (master’s or doctoral) programs, which include
    didactic and clinical courses designed to prepare
    graduates with specialized knowledge and clinical
    primary care competencies. Members of the
    profession are responsible for advancing the NP
    role, specifying the professional standards and
    competencies, as well as ensuring that these are
    met.
    NP Commitment to Primary Care
    Almost all NPs (89%) are prepared in a
    primary care focus; e.g. adult, family,
    gerontological, pediatric, or women’s health.
    The family NP focus is the most prevalent
    category (see below). Regardless of their
    population focus, primary care NPs are
    prepared to fulfill the definition of primary
    care across settings, including the provision
    of care at first contact for undifferentiated
    conditions, ,ongoing management of acute
    and chronic conditions, health promotion,
    and care coordination.
    Specialty Percent
    Acute Care 5.3
    Adult 17.9
    Family 49.2
    Gerontological 3.0
    Neonatal 2.3
    Oncology 0.8
    Pediatric 9.4
    Psychiatric/Mental Health 2.9
    Women’s Health 9.1
    NP Growth
    The enrollment and graduation rates of NP
  4. by   nomadcrna
    http://www.ena.org/SiteCollectionDoc...hite_Paper.pdf

    Advanced practice registered nurses working in emergency settings are experienced providers. In a
    survey of 166 advanced practice registered nurses who worked in emergency departments,
    approximately two-thirds (63%) of the respondents were nurse practitioners, 28% were clinical
    nurse specialists, and 9% were both nurse practitioners and clinical nurse specialists.
    8
    The
    respondents had practiced professional nursing for about 15 years before becoming advanced
    practice registered nurses, and most had worked as an advanced practice registered nurse in the
    emergency department for more than 5 years.
    8
    Currently, there are no national specialty
    certifications for nurse practitioners or clinical nurse specialists practicing in emergency care
    settings; however, many advanced practice registered nurses hold a national certification for
    practice as a nurse practitioner or clinical nurse specialist. Advanced practice registered nurses in
    emergency settings reported being certified most often as family nurse practitioners (43%), acute
    care nurse practitioners (13%), adult care nurse practitioners (12%), pediatric nurse practitioners

    (7%), women’s health nurse practitioners (<1%), critical care clinical nurse specialists (9%),
    medical-surgical clinical nurse specialists (5%), pediatric clinical nurse specialists (<1%), and
    other clinical nurse specialists (10%).
    8
    Last edit by nomadcrna on Mar 16, '12
  5. by   LiLoRN
    National Organization of Nurse Practitioner Faculties: Consensus Model for APRN Regulation

    If you look here, you can see what the National Organization of Nurse Practitioner Faculties has to say about scope of practice for Acute vs Primary NP's. I'm attending FNP school, and the administration there is adament that we are being prepared only for outpatient primary care and won't even allow us to do clinicals in a hospital. They also state that when they receive requests for recommendations from hospitals about possible employment for grads, they reply to them that we are trained only for outpatient primary care.
  6. by   nomadcrna
    I am familiar with the consensus model. We are discussing it at our state board now. A few states have passed it but it remains to be seen if more do the same. Many rurual states (mine included) do not like the wording as many ERs ar staffed by FNPs.
    The model is meeting much resistance in our state and may not pass.
    If you read it, you will see that the FNP can still do ER and inpatient care. Intensive care will not be within the scope though.
    It remains to be seen if the states will jump on board with the consensus model.
    I am against it until the NP schools get their act together. A much better model would be a broad based basic program that incorporates all populations then specialize afterwards. The DNP is a perfect road to that end.

    focus. For example, a family CNP could specialize in elder care or nephrology; an Adult-Gerontology CNS could specialize in palliative care; a CRNA could specialize in pain management; or a CNM could specialize in care of the post-menopausal woman. State licensing boards will not regulate the APRN at the level of specialties in this APRN Regulatory Model. Professional certification in the specialty area of practice is strongly recommended.
    An APRN specialty
    • preparation cannot replace educational preparation in the role or one of the six population foci;
    • preparation can not expand one’s scope of practice beyond the role or population focus
    • addresses a subset of the population-focus;
    • title may not be used in lieu of the licensing title, which includes the role or role/population; and
    • is developed, recognized, and monitored by the profession.
    New specialties emerge based on health needs of the population. APRN specialties develop to provide added value to the role practice as well as providing flexibility within the profession to meet these emerging needs of patients. Specialties also may cross several or all APRN roles. A specialty evolves out of an APRN role/population focus and indicates that an APRN has additional knowledge and expertise in a more discrete area of specialty practice. Competency in the specialty areas could be acquired either by educational preparation or experience and assessed in a variety of ways through professional credentialing mechanisms (e.g., portfolios, examinations, etc.).
    Education programs may concurrently prepare individuals in a specialty providing they meet all of the other requirements for APRN education programs, including preparation in the APRN core, role, and population core competencies. In addition, for licensure purposes, one exam must assess the APRN core, role, and population-focused competencies. For example, a nurse anesthetist would write one certification examination, which tests the APRN core, CRNA role, and population-focused competencies, administered by the Council on Certification for Nurse Anesthetist; or a primary care family nurse practitioner would write one certification examination, which tests the APRN core, CNP role, and family population-focused competencies, administered by ANCC or AANP. Specialty competencies must be assessed separately. In summary, education programs preparing individuals with this additional knowledge in a specialty, if used for entry into advanced practice registered nursing and for regulatory purposes, must also prepare individuals in one of the four nationally recognized APRN roles and in one of the six population foci. Individuals must be
    APRN Joint Dialogue Group Report, July 7, 2008
    13
    recognized and credentialed in one of the four APRN roles within at least one population foci. APRNs are licensed at the role/population focus level and not at the specialty level. However, if not intended for entry-level preparation in one of the four roles/population foci and not for regulatory purposes, education programs, using a variety of formats and methodologies, may provide licensed APRNs with the additional knowledge, skills, and abilities, to become professionally certified in the specialty area of APRN practice.
  7. by   nomadcrna
    That is a shame. I did a huge amount of ER and inpatient medicine in my program. I was with two great family practice docs who literally did it all. I did clinic with them, followed the inpatients and did many hours in the ER with them as well.

    Quote from LiLoRN
    National Organization of Nurse Practitioner Faculties: Consensus Model for APRN Regulation

    If you look here, you can see what the National Organization of Nurse Practitioner Faculties has to say about scope of practice for Acute vs Primary NP's. I'm attending FNP school, and the administration there is adament that we are being prepared only for outpatient primary care and won't even allow us to do clinicals in a hospital. They also state that when they receive requests for recommendations from hospitals about possible employment for grads, they reply to them that we are trained only for outpatient primary care.
  8. by   KCEG
    This is a very interesting topic to me personally.

    I am getting ready to apply to Vanderbilt's PreSpecialty FNP Program, and was told at their open house that they are working with the TN BON to clarify FNP and ACNP training and scope of practice.

    The Director of the ACNP program told me that in TN FNP's had no business practicing in the ED or working as a hospitalist, and she said that the BON is working to clarify the appropriate environments for Advanced Practice Nurses.

    I currently plan to return to Texas unless an attractive offer presents itself in an unrestricted state, and know several hospitals here where FNP's work in the Emergency Room, and as hospitalists, especially in facilities that are located outside metropolitan areas.

    Flexibility is high on my list of priorities when looking at Advanced Practice Opportunities after working in healthcare most of my career, and I'm not sure how concerned I should be with the information I've been hearing in relation to practice areas and restrictions.

    If a graduate is not academically trained in school to provide care to inpatients and ER's, is it possible to obtain this training after graduation by working in places that offer learning opportunities? How much of this is dictated by facilities and credentialing, as opposed to Boards of Nursing? Is it necessary to return for ACNP certification and be dual-credentialed to be "qualified" under the scenario that is being described?

    I apologize for all of the questions, but any insight that can be provided by currently practicing FNP's would be greatly appreciated. It seems there is significant confusion and difference of opinion from person to person and state to state on this issue.

    Thank you,
    KCEG
  9. by   nomadcrna
    Dual credentialling is your best bet. Vanderbilit has a nice dual program.
    Many states you won't have an issue unless you try to work as an intensivist. But ER and inpatient has never been a problem for me.
    Inpatient especially as that is an extension of primary care. ER may be more iffy in the future although fnPs are the only NPs that can really do it due to age restrictions.
  10. by   CCRNDiva
    I went to an open house at Vanderbilt last year and they were very explicit about the roles of FNP and ACNP. My current school divides their focus as well. You can "specialize" your clinical experiences but only with additional coursework and clinical hours. For instance, a FNP or ANP can focus on cardiology, oncology, or emergency but only with taking the additional courses and clinicals for those specialties. The ACNPs can choose to focus on critical care or emergency.

    I find that the medical arena is trending the same way. Family practice docs do not do many procedures in my area. Most FPs do not even round on their own hospitalized patients here. They may suture small wounds or do small biopsies, but often you are referred to a specialist. If you need an endoscopy, you are referred to GI. Many docs are not allowed to independently manage patients in the ICU. They have to submit proof of applicable training or education to be credentialed to independently manage critically ill patients. My son had a cyst on shin, we were referred to a GV surgeon. It all goes back to training. The days of the generalist being the jack of all trades is over. Residents are not able to get the training to learn how to manage everything with the limitations on hours. I've had the opportunity to work with many docs in my area and if I'm admitted to the ICU, I want a board certified intensivist, trauma surgeon or the like coordinating my care. I've seen a difference in the quality of care provided by the FPs in comparison to those whose training programs focused on critical care or the like. That doesn't mean they're bad docs, they just don't have the training or experience with procedures or critically ill patients.
  11. by   nomadcrna
    Yep, urban areas are that way. Probably for the best.
    Rural areas though are a whole different ball game.

    I agree. A specialist would be idea. Come to a rural area and try to find one. Try to find a residency trained ER physician. You won't find them. Look around for a hospitalist,nope. There is not even a surgeon in our town.
    Do you want NO care or at least some care until you are transfered out?
    There is more to the medical world then big urban cities.
    Nobody is talking about FNPs or family practice physicians providing sole care in a urban ICU. Not anytime as that been mentioned. We are discussing FNPs doing RURAL ER and inpatient.
  12. by   BlueDevil,DNP
    KCEG:
    I always recommend to familiarize yourself with the laws where you want to practice. I do not live in a rural area; we are approaching 1,000,000 residents and are not deemed underserved. However, FNPs are frequently employed here as intensivists, hospitalists and in the ED (please keep in mind I live in a state with wholly independent NP practice). I know a FNP that does 1 days in a clinic and 1 day in an ED every week, runs her own weight loss clinic, and does prn in a neuro critical care unit, lol.
    I suspect it is because the 1 NP program in the area does not offer ACNP options, and there are very few ACNPs to be found. The few that there are are all transplants from out of state. Areas that have an education pathway available for ACNP are probably going to use them preferentially in applicable areas. Know your area.
    Rural areas in my state have NPs that practice like family practice/generalist physicians of yore. They see everyone for every thing and are completely responsible for their inpatients. In fact, the work load and responsibilities are so great that they cannot attract NPs to those areas (MDs having left 20 years ago) anymore. An hour or two outside a city offering a plethora of choices is a far cry from 6 hours from the nearest trauma center, lol! My point being, even differentiating rural vs urban is not enough. Know the state law, the culture and needs of the area where you want to live and make your decision based upon those factors.
    good luck!
  13. by   KCEG
    Thank you for the responses, Nomad, BlueDevil and Diva. I sincerely appreciate it.

    I'm not sure exactly where I want to practice geographically, which complicates things. I may practice in Texas, but I'm also willing to relocate to another part of the country depending on the options I find available at graduation. I know I will have much to learn even after completing school, but I am very intrigued by the states that allow independent practice.

    Thanks again for your willingness to answer my questions.

    Best Regards,
    KCEG

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