Orthopedic FNP Texas

core0 · Mar 1, 2013

Hello all
I'm currently in the FNP program at Texas Tech, due to graduate in August and trying to figure out what to do afterwards. My background is ICU for 2 years and Ortho for the last 3 years. I always thought I would go to Family Practice when done with my FNP but, as I am nearing completion of my program, Ortho surgeons I work with are asking me about potentially joining their respective practices. While I love the idea of staying in Ortho, I am unsure of what my role, as an FNP, would be.
I realize seeing patients in clinic- injuries, pre-op, and post-op would be a big part of it so the surgeon could be in the OR where he makes his big $$$. But the surgeons I work with employ PAs and don't seem to think there is a difference between the two. I see PAs assist in the OR frequently, but as an FNP, the only way I could do that is with an RNFA, correct?
Also, they could not ask me to round or deal with anything inpatient, correct? I really wish Tech offered a course on this type of issue as I am months away from graduation and am unclear of my scope in this field. Anyone who has a clue about how this works in Texas, please advise.
Thanks

Two problems. First you are correct you would need an RNFA to work in the OR:

Q: What requirements need to be met for advanced practice nurses who want to first assist and be reimbursed for their services?

A: HB 1718, passed in the 79th Regular Legislative Session (2005), amended the Nursing Practice Act to include Section 301.353. This section defines a nurse first assist as an individual who:

Is licensed to practice as a RN,
Has completed a nurse first assistant educational program approved or recognized by an organization recognized by the board, and
Is either (1) certified in perioperative nursing (CNOR) OR (2) recognized by the board as an advanced practice nurse and qualified by education, training or experience to perform the tasks involved in perioperative nursing.

Second problem:

APN Scope of Practice

You are an FNP trying to work in an acute care specialty.

Talk to the BON but in all likelihood you would need to get a post graduate ACNP (and a ANCP-P if they see patients under 13) to work there.

bsnanat2 · Mar 1, 2013

Actually, as an Advance Practice Nurse you do not need RNFA to assist. CMS automatically recognizes APRN's (NP's etc.) to assist. The issue is often that NP programs do not include a surgical rotation. The other issue is the facility credentialing. The previous poster was referring to RN's. Look at NIFA. They have a program specifically for NP's to get the necessary skills to First Assist. It includes an online didactic portion then a six day intensive hands-on session. They have payment plans available and your practice will most likely reimburse you once you're set with them. Check it out and go for it. Orthos are usually great to work with.

core0 · Mar 2, 2013

Actually, as an Advance Practice Nurse you do not need RNFA to assist. CMS automatically recognizes APRN's (NP's etc.) to assist. The issue is often that NP programs do not include a surgical rotation. The other issue is the facility credentialing. The previous poster was referring to RN's. Look at NIFA. They have a program specifically for NP's to get the necessary skills to First Assist. It includes an online didactic portion then a six day intensive hands-on session. They have payment plans available and your practice will most likely reimburse you once you're set with them. Check it out and go for it. Orthos are usually great to work with.

Read the quote above. Texas requires RNFA course and either a CNOR or NP. CMS is completely different. On the other hand its relatively easy (although expensive) to get the RNFA training. The inpatient role is going to be a different problem.

littlebelle1293 · Mar 3, 2013

Thanks for the replies. Yes, I thought I could not see inpatients I just wanted to be sure. I have no interest in rounding in the hospital, that is the main reason I went for FNP instead of ACNP. Also, I liked the ability to see across the lifespan not just >13yrs.

So when it come to the RNFA. I have glanced at the NIFA site and have seen the RNFA course they have specifically for NPs. My understanding from the Texas BON was that I could take this course or some other course designed to teach first assisting to nurses, would likely need to prove my newly acquired skills to facilities for credentialing, but would not need to sit for the CNOR or any other additional certification- that proof of course completion and ability to prove my skills in order to cover my back side would suffice. Is this correct?

Further, if the surgeon just wanted me in clinic, no OR, no hospitals, no additional education or certification would be required. Again, correct? While I would like to eventually be a certified ONP (orthopedic NP) I can't sit for that exam until I've got 2,000 hours as an NP working in orthopedics. Thanks for the guidance.

core0 · Mar 4, 2013

Thanks for the replies. Yes, I thought I could not see inpatients I just wanted to be sure. I have no interest in rounding in the hospital, that is the main reason I went for FNP instead of ACNP. Also, I liked the ability to see across the lifespan not just >13yrs.
So when it come to the RNFA. I have glanced at the NIFA site and have seen the RNFA course they have specifically for NPs. My understanding from the Texas BON was that I could take this course or some other course designed to teach first assisting to nurses, would likely need to prove my newly acquired skills to facilities for credentialing, but would not need to sit for the CNOR or any other additional certification- that proof of course completion and ability to prove my skills in order to cover my back side would suffice. Is this correct?
Further, if the surgeon just wanted me in clinic, no OR, no hospitals, no additional education or certification would be required. Again, correct? While I would like to eventually be a certified ONP (orthopedic NP) I can't sit for that exam until I've got 2,000 hours as an NP working in orthopedics. Thanks for the guidance.

ONP isn't a recognized certification. You can look at the Texas BON to see what they recognize. As far as working in the clinic you could conceivably do that, however you would have to worry about possible BON action if someone complained.

kguill975, MSN, APRN, NP · Mar 4, 2013

I'm a surgical NP, and I completed the fast track NIFA course. I'm already a CNOR, so I didn't have to take the 6 day course. Since you don't have OR experience, they'll tell you to take the full course. There's some videos you'll have to watch, attend the workshop, and then it's pretty much the same coursework that everyone takes. You don't need OR experience or CNOR since you're an APN. After you finish the course requirements and the 120 hours of Ortho cases, you'll get your certificate and you're good to go.

We have a FNP that's currently getting her hours for RNFA. She works in the general surgery clinic an sees all ages. She also sees new consults in the ER, and does pre-ops and post-ops. The only thing she doesn't do is inpt management.

littlebelle1293 · Mar 4, 2013

Thanks so much kguill, that is very helpful and was exactly what I was understanding based on what I've read. I've spoken to a peer who runs an OR for some of the Orthopods I work with and she has offered to give me training in the OR for the last semester of my FNP program. While I know I won't reach some high # of OR hours and would still want to take the full NIFA course, I'm at least looking to get my feet wet.

TX RN · Mar 4, 2013

I see FNP's round in hospitals in the part of Texas where I'm at.

It's not that uncommon.

Best of luck.

littlebelle1293 · Mar 4, 2013

Thanks TX RN,

I too have seen the same thing in Austin hospitals. While I don't feel that I would be prepared to see inpatients based on Texas Tech's FNP program, there are others who have better experiences or additional education that could give them that ability.

Core0, I can't seem to understand why an FNP working in the clinic setting only (no inpatient no OR) of an orthopedic practice would be working outside of their scope. FNPs in primary care clinics see patients with orthopedic complaints, and have completed instruction on medical management of those disorders, giving joint injections, splinting, etc... Could you clear this up for me a bit? Is this because it is a Surgical practice?

core0 · Mar 4, 2013

Thanks TX RN,
I too have seen the same thing in Austin hospitals. While I don't feel that I would be prepared to see inpatients based on Texas Tech's FNP program, there are others who have better experiences or additional education that could give them that ability.
Core0, I can't seem to understand why an FNP working in the clinic setting only (no inpatient no OR) of an orthopedic practice would be working outside of their scope. FNPs in primary care clinics see patients with orthopedic complaints, and have completed instruction on medical management of those disorders, giving joint injections, splinting, etc... Could you clear this up for me a bit? Is this because it is a Surgical practice?

Its all going to depend on your risk tolerance. If you were in New Mexico for example where the BON interprets the roles quite liberally and no collaboration agreement is required then you would probably be fine. On the other hand if you choose to practice where the BON interprets the role very tightly then you are one complaint away from losing your job. If you look at what the BON says:

Determining scope of practice includes:

Advanced practice education in a role and specialty
Legal implications (e.g. compliance with the Nursing Practice Act and Board Rules)
Scope of practice statements as published by national professional specialty and advanced practice nursing organizations

You can read it any way you choose. One way is as you stated that FNPs in primary care see orthopedic complaints. The other way is that specialty practice in orthopedics is outside the scope of someone trained in primary care. I'm sure that there are FNPs practicing in Texas hospitals. I am also sure that the BON would take a dim view of it when the found out.

We are going through this currently here. The hospital has given FNPs that work in critical care more than 50% of the time 1 year to get their ACNP. The suspicion is that this will move to all inpatient positions over the next few years. The state BON has refused to rule on scope issues saying its up to the individual nurse to make sure they are in compliance. On the other hand the state BOM has to sign off on all collaboration agreements. Under the current rules they would probably find that orthopedics is not a primary care specialty and an orthopod could not collaborate with an FNP.

Like I said you can try to stretch an FNP to fit a situation, it just depends on your risk tolerance.

TX RN · Mar 4, 2013

The following were taken from the 2008 Consensus APRN model.

The link is provided on the Texas BON website.

I think you're ok. Get the speciality certification once you have completed hours.

Also document and keep any and all training in your specialty. All for CYA reasons.

http://www.bon.texas.gov/practice/pdfs/aprnmodel.pdf

http://www.bon.texas.gov/practice/gen-apn.html

"Scope of practice of theprimary care or acute care CNP is not setting specific but is based on patient care needs. Programs may

prepare individuals across both the primary care and acute care CNP competencies."

"Preparation in a specialty area of practice is optional, but if included must build on the APRNrole/population-focused competencies. Specialty practice represents a much more focusedarea of preparation and practice than does the APRN role/population focus level. Specialtypractice may focus on specific patient populations beyond those identified or health care

needs such as oncology, palliative care, substance abuse, or nephrology."

"State licensing boards will not

regulate the APRN at the level of specialties in this APRN Regulatory Model."