What are the roles of FNPs in hospitals?

[BerkeleyMom]

Hello Everyone,

New member here--sorry if this is in another thread and I will gladly go there if you direct me. I have shadowed FNPs and spoken with students in the program that I am applying to. I am only familiar with the role of an FNP in outpatient clinics and programs. I am wondering what other avenues FNPs can take that do not involve primary care.

I would like to learn about the prospects of working in a hospital. Are you an FNP that works in a hospital, or do you work with them in your hospital? What is your/their job description and why do you/they prefer it over primary care? Is this a common thing, or is there much additional training and degrees required?

I know there are numerous specialties, I am just wondering if an FNP degree can be limiting in this sense.

Thank you in advanced.

[mvanz9999, RN]

....However, the vast majority of the jobs that involve specialty practice want both inpatient and outpatient coverage. This is a job that previously had been filled by PA's and FNP's or ANP's with the new criteria that I see being put into place you would need an ACNP and an FNP/ANP to work the position. Going back to the OP's question, yes there are roles for FNP's in hospitals, but they seem to be going away.

.....If you look at the example of an ortho NP, in some states you would need an RNFA, ACNP, and FNP to fulfill all the requirements.

David Carpenter, PA-C

I see your point and it makes sense, but my question is *who* is going to do all that (ie, get RNFA, ACNP, and FNP) to work in ortho? The pay wouldn't equal the cost of education, not to mention the years required to get all this training. I don't believe those requirements are sustainable except for a few insane people that just love to be in school and pay lots of tuition. And for the cost and no. of years in school, you might as well go to med school.

If all this holds true, then I think APNs will be phased out because no one is going to want to get all those certifications.

[core0]

I see your point and it makes sense, but my question is *who* is going to do all that (ie, get RNFA, ACNP, and FNP) to work in ortho? The pay wouldn't equal the cost of education, not to mention the years required to get all this training. I don't believe those requirements are sustainable except for a few insane people that just love to be in school and pay lots of tuition. And for the cost and no. of years in school, you might as well go to med school.

If all this holds true, then I think APNs will be phased out because no one is going to want to get all those certifications.

I think that it points out the difficulty of trying to force a nursing model on a medical world. This is probably the primary reason that PA's tend to dominate the surgery market. The real problem I see with the APN model is the lack of training in both inpatient and outpatient medicine. The DPN may solve this problem somewhat or you may see more dual programs such as the one mentioned above. There will still be an APN market in the market that they were originally designed for - primary care.

David Carpenter, PA-C

[mvanz9999, RN]

I think that it points out the difficulty of trying to force a nursing model on a medical world. This is probably the primary reason that PA's tend to dominate the surgery market. The real problem I see with the APN model is the lack of training in both inpatient and outpatient medicine. The DPN may solve this problem somewhat or you may see more dual programs such as the one mentioned above. There will still be an APN market in the market that they were originally designed for - primary care.

David Carpenter, PA-C

So, in your opinion, becoming an Acute Care Nurse Practitioner could actually be a huge mistake?

[core0]

So, in your opinion, becoming an Acute Care Nurse Practitioner could actually be a huge mistake?

No I think that there is a role for them in Hospitalist medicine and in academic centers where there is less concern over reimbursement. In specialty medical practice and especially surgery there is less of a role because of the clinic issue. Also there is a role in urgent care and probably ER. However if you look at where the money comes from in specialty practice it is in the clinic in downstream revenue and income redirection through increased consults. I would also worry about an income squeeze if ICU nursing salaries continue to go up.

David Carpenter, PA-C

[prairienp]

i think that it points out the difficulty of trying to force a nursing model on a medical world. this is probably the primary reason that pa's tend to dominate the surgery market. the real problem i see with the apn model is the lack of training in both inpatient and outpatient medicine. the dpn may solve this problem somewhat or you may see more dual programs such as the one mentioned above. there will still be an apn market in the market that they were originally designed for - primary care.

david carpenter, pa-c

who is trying to force the nursing model on a medical world? i thought we were all practicing a form of "healthcare". the reason pas dominate surgical is they have always sought those roles, "supervisory". historically nps have sought outpatient sites secondary to the original design of the np curriculum. the development of the dnp will allow those nps who desire surgical experience (or any other specialty) to design their plan of study to include the non-traditional learning experience.

[core0]

who is trying to force the nursing model on a medical world? i thought we were all practicing a form of "healthcare". the reason pas dominate surgical is they have always sought those roles, "supervisory". historically nps have sought outpatient sites secondary to the original design of the np curriculum. the development of the dnp will allow those nps who desire surgical experience (or any other specialty) to design their plan of study to include the non-traditional learning experience.

what i was referring to was the nursing specialties. these are different than medical specialties and have different limitations. the fnp model was not conceived to provide healthcare for inpatients just as the acnp was not conceived to provide healtchcare for outpatients. now the acnp is becoming more common and the hospitals are more concerned over the credentialling of npp's they are properly asking the question can these providers demonstrate competency in the inpatient setting. in some cases the fnp cannot while the acnp can. these are nursing models limited to a field of nursing. like it or not most of the world functions on a medical model which looks at disease states not the setting the patient was seen in. in a medical specialty the patient moves accross the inpatient and outpatient setting and healthcare needs to be delivered in both settings. it is inefficent to have to hire different people to do this.

while you are correct that historically np's have sough outpatient work there are a substantial number that do inpatient work. depending on the state they are in and the terms of their certification they may be outside the scope of practice. this has largely been ignored due to a lack of physician understanding of nursing practice and a lack of incentive for other bodies to look at this. this has now become a very hot topic for hospitals as part of the credentialling process.

the inherent problems with nursing regulation and employment by a physician are where the nursing model clashes with the medical model.

david carpenter, pa-c

[Corey Narry, MSN, RN, NP]

just some fyi on acute care nurse practitioners as defined by an np specialty board (ancc) and an acnp program (rush u.):

acnp definition from ancc:

the acute care nurse practitioner (acnp) is a registered nurse with a graduate degree in nursing who is prepared to manage the health care of acutely ill patients at an advanced level. acnps use a collaborative model in their practice to provide direct services to acutely, critically or chronically ill adult patients in a variety of settings. the acnp's advanced education and practice skills, along with diagnostic reasoning and advanced therapeutic interventions experience, are the key elements to provide quality care to their patients. the acnp also uses skills in consultation, collaboration, and systems management to provide effective restorative care. the practice includes independent and interdependent decision making and the acnp is directly accountable for clinical judgments.

acnp info from rush u.

the role

[color=#009999]the master of science in nursing (msn) acute care nurse practitioner program prepares graduates to function as advanced practice nurses in adult critical/acute care. the emphasis of the program is on clinical practice with acutely or critically ill adults that prepares practitioners to function autonomously across the spectrum of health care in a variety of settings. the acnp student will gain an in-depth knowledge of nursing theory and research, critical decision-making, differential diagnosis, patient/case management, and technical intervention skills related to health maintenance, health restoration, and illness prevention.

clinical sites

rush university medical center offers graduate practitioner students clinical experiences in a wide variety of settings with a focus on managing a caseload of acutely/critically ill patients. practicum sites include acute in-patient hospital units, general and specialty intensive care units, emergency departments, sub-acute care institutions, and specialty acute care practices (e.g., cardiology, neurosurgery, bone marrow transplant).clinical practice experiences are planned on a student-centered basis by rush college of nursing faculty. planning is based on individual student learning needs, available clinical sites and preceptors, and specifically designed clinical objectives.

career opportunities

career opportunities for acute care nurse practitioners cross the spectrum of healthcare. acute care nurse practitioners provide care in a variety of acute and critical care settings in tertiary and community hospitals, as well as diverse settings in private practices. they function independently and collaboratively with a variety of adult acute/critical care providers to deliver quality, evidence-based care that will maximize patient care outcomes.

certification and accreditation

completion of the acnp program provides eligibility for certification as an acute care nurse practitioner by the american nurses credentialing center of the american nurses association and for state licensure/certification where available.

there is also a publication by aacn entitled "scope of practice for the acute care nurse practitioner".

[core0]

Just some FYI on Acute Care Nurse Practitioners as defined by an NP specialty board (ANCC) and an ACNP program (Rush U.):

ACNP definition from ANCC:

The Acute Care Nurse Practitioner (ACNP) is a registered nurse with a graduate degree in nursing who is prepared to manage the health care of acutely ill patients at an advanced level. ACNPs use a collaborative model in their practice to provide direct services to acutely, critically or chronically ill adult patients in a variety of settings. The ACNP's advanced education and practice skills, along with diagnostic reasoning and advanced therapeutic interventions experience, are the key elements to provide quality care to their patients. The ACNP also uses skills in consultation, collaboration, and systems management to provide effective restorative care. The practice includes independent and interdependent decision making and the ACNP is directly accountable for clinical judgments

This is from the ACNP 2004 competencies:

Based on educational preparation, ACNPs practice with a focus on a variety of specialty based populations including neonatal, pediatric, and adult. The ACNP practices in any setting in which patient care requirements include complex monitoring and therapies, high-intensity nursing intervention, or continuous nursing vigilance within the range of high-acuity care. While most ACNPs practice in acute care and hospital based settings including sub-acute care, emergency care, and intensive care settings, the continuum of acute care services spans the geographic settings of home, ambulatory care, urgent care, and rehabilitative care.

I see definition problems here. While some of what we do in specialty practice is acute care for the most part it is clinical management of chronic illness or work up of sub acute illness. I would not rate this high acuity care. This is very similar to the problem I see with other defiintions of nursing practice. Who decides what is acute care? For example take this from the Colorado Nurse practice act:

(b) An advanced practice nurse may be granted authority to prescribe prescription drugs and controlled substances to provide treatment for persons requiring:

(I) Care for an acute self-limiting condition;

(II) Care for a chronic condition that has stabilized; or

(III) Terminal comfort care.

© For purposes of this subsection (3), "self-limiting condition" means a condition that has a defined diagnosis and a predictable outcome and is not threatening to life or limb.

So if you look at this from a ACNP standpoint it would be very difficult to prescribe in the hospital since most conditions are either a non-stabilized chronic condion or are not self-limiting. Is this enforced in practice - no, but hundreds of prescriptions are written every day that are outside of the nurse practice act. This is a classic example of trying to define nursing practice to fit guidelines that do not follow the way the world works.

So what is the nursing basis for an ACNP in a clinic. Can they only see acute problems (including exacerabation of chronic conditions)? Similary could a FNP see acute patients in the hospital or only patients with chronic conditions.

David Carpenter, PA-C

[Corey Narry, MSN, RN, NP]

My interpretation of ANCC's definition is that acute care NP scope is not limited to hospital settings. ACNP training is specialty-driven since patients seen have exisiting acute or chronic illness. For example, an ACNP can work with a private practice group of Nephrologists. A typical progression for patients through this specialty involves a consult in the hospital for kideny disease by an NP in collaboration with a nephrologist. Then, the decision for treatment is made. Let's say the patient ends up requiring hemodialysis. The ACNP can follow this patient through the hospital course. At discharge, the ACNP still has a role seeing the patient in the nephrology clinic because even though this is an out-pt setting, this is still specialty practice. The ACNP is not providing primary care in this situation.

It is also a misconception that all ACNP clinical placements are in hospital settings. ACNP clinical placements are individualized based on the student's goals after graduation. Some students opt to rotate in a strictly hospitalist internal medicine rotation. Some prefer to concentrate on cardiology. Those that do that are usually paired with a cardiologist and their clinical rotations include hospital, cath lab, and clinic. I did an internal medicine, adult urgent care, cardiology (in-patient and clinic), and pulmonary and critical care rotation in my program and I specifically asked for these choices to the program director.

The way nursing boards use language is subject to varying interpretations. It is the responsibility of the hiring physician to decide if a prosepctive NP employee is competent or trainable enough to be hired. Based on the pattern I am seeing, physicians do not have a problem with that. The Colorado Nursing Act is a perfect example of restrictive language. This does not help advance practice nursing at all. It is probably not meant to be that way but the powers that be that decided on that language did not realize the dynamic nature of medicine and advanced practice nursing at the time it was written. Fortunately, I am not faced with that situation in my state. This is the reason why there is always a bit of political activism involved in being an NP.

[core0]

My interpretation of ANCC's definition is that acute care NP scope is not limited to hospital settings. ACNP training is specialty-driven since patients seen have exisiting acute or chronic illness. For example, an ACNP can work with a private practice group of Nephrologists. A typical progression for patients through this specialty involves a consult in the hospital for kideny disease by an NP in collaboration with a nephrologist. Then, the decision for treatment is made. Let's say the patient ends up requiring hemodialysis. The ACNP can follow this patient through the hospital course. At discharge, the ACNP still has a role seeing the patient in the nephrology clinic because even though this is an out-pt setting, this is still specialty practice. The ACNP is not providing primary care in this situation.

It is also a misconception that all ACNP clinical placements are in hospital settings. ACNP clinical placements are individualized based on the student's goals after graduation. Some students opt to rotate in a strictly hospitalist internal medicine rotation. Some prefer to concentrate on cardiology. Those that do that are usually paired with a cardiologist and their clinical rotations include hospital, cath lab, and clinic. I did an internal medicine, adult urgent care, cardiology (in-patient and clinic), and pulmonary and critical care rotation in my program and I specifically asked for these choices to the program director.

The way nursing boards use language is subject to varying interpretations. It is the responsibility of the hiring physician to decide if a prosepctive NP employee is competent or trainable enough to be hired. Based on the pattern I am seeing, physicians do not have a problem with that. The Colorado Nursing Act is a perfect example of restrictive language. This does not help advance practice nursing at all. It is probably not meant to be that way but the powers that be that decided on that language did not realize the dynamic nature of medicine and advanced practice nursing at the time it was written. Fortunately, I am not faced with that situation in my state. This is the reason why there is always a bit of political activism involved in being an NP.

This is the kind of thing that drives credentialling boards crazy. If they look at a physician they know what they are getting on the basis of the residency. Now you have to evaluate each NP on the basis of their individualized training. We really don't use ACNP's around here, but I have received an education. I will also say that the Rush program seems to be more the exception in placing students in clinics since most of the programs I have looked at place students in inpatient, ICU, ER and urgent care clinics. In discussing this with the faculty at the Pueblo program reference above they disagree with you that it is within the scope of practice for an ACNP to see clinic patients (they may have a bias since they created the dual ANP/ACNP program). Their concern is that there is not sufficent time to cover adult medicine and critical care medicine within the timeframe of the ACNP program.

As far as your comment on providing primary care, I can tell you from six years experience in specialty care, a lot of what we do is expanded primary care. If you are working in a clinic and don't have a good concept of primary care medicine you will be a hinderance.

To further cloud the ACNP issue, apparently there is another certification exam coming from the AACN

Notice that the ANCC describes ACNP this way:

"ACNPs use a collaborative model in their practice to provide direct services to acutely, critically or chronically ill adult patients in a variety of settings."

While the AACN describes it this way:

"AACN Certification Corporation is now developing an Acute Care Nurse Practitioner certification exam, which is aligned with our mission to provide comprehensive credentialing for nurses to ensure their practice is consistent with established standards of excellence in caring for acutely and critically ill patients and their families."

They will also be publishing their own set of scope of practice rules seperately. So you will have two organizations certifying the same title (ACNP) with different definitions of the job and different scope of practices.

Pretty confusing.

David Carpenter, PA-C

[Corey Narry, MSN, RN, NP]

There's still a lot of work to be done. The NP role is young and still evolving. It doesn't help that nursing fields have earned the notorious distinction of being divided in many respects. The one thing nursing prides itself in is our commitment to the patient as a whole human being. That always saves us. I don't know the ultimate solution to all these confusion - maybe the DNP, maybe combined programs, time will tell.

I myself am questioning why AACN is coming up with a new and improved ACNP board exam. AACN and ANCC used to jointly administer the exam way back and the relationship split because of difference in opinions about the role to begin with. It hurts my head thinking about it.

[mvanz9999, RN]

.....

I myself am questioning why AACN is coming up with a new and improved ACNP board exam. AACN and ANCC used to jointly administer the exam way back and the relationship split because of difference in opinions about the role to begin with. It hurts my head thinking about it.

Once again, if it hurts your head and you ARE ACNP, imagine the confusion to those of us who are just looking into getting trained as ACNP, and cannot get a straight answer about what they can or cannot do.