I'll touch on your second question by saying check with your state BON. Independent practice for ANY NP varies by state. The acute care vs. family/primary care debate continues to argued, so I don't know if there is a clear answer. I know in my state, Ohio, the BON has issued an opinion that acute care should focus on acutely ill inpatient, hospital based clients and primary care NPs (WHNP,FNP,ANP, PNP) are just that, providers of primary, outpatient care. This is based on guidelines from the National Organization of Nurse Practitioners Faculties:
According to the competencies set forth by the National Organization of Nurse Practitioner Faculties (NONPF),2 the Scope and Standards of Practice for the ACNP (acute care nurse practitioner),3 and NAPNAP,4 acute care nurse practitioners are educationally prepared to provide advanced nursing care to patients with complex acute, critical and chronic health conditions, including the delivery of acute care services, such as those patients found in the critical care areas throughout the hospital. These programs of study do not contain adequate clinical and didactic content to support the ACNP for a broader role in outpatient primary care diagnosis, treatment, and follow-up. In contrast, adult, women, geriatric, family and some pediatric nurse practitioners educational focus is on primary care. For instance, the family nurse practitioner is a specialist in family nursing, in the context of community, with broad knowledge and experience with people of all ages.5 NPs prepared with a primary care focus primarily practice in ambulatory care settings, including family medical practices and women health centers. This environment of primary care is not congruent with the acute care secondary or tertiary care training focus. A lack of congruence between the practice environment and level of expertise results in a decreased level of safety for the patient and increased risk of liability for the CNP.6,7
The Consensus Model goes on to say:
The certified nurse practitioner (CNP) is prepared with the acute care CNP competencies and/or the primary care CNP competencies. Scope of practice of the primary 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. If programs prepare graduates across both sets of roles, the graduate must be prepared with the consensus based competencies for both roles and must successfully obtain certification in both the acute and the primary care CNP roles. CNP certification in the acute care or primary care roles must match the educational preparation for CNPs in these roles.
There are still some grey areas. Is ER considered to acute for an FNP? Derm may be okay for an FNP, but is cardio ACNP only? No one really knows. So, many hospitals are making their FNPs working inpatient go back and add ACNP and any ACNPs in primary care are being told they need to get their FNP/ANP within a certain time frame. The BON isn't saying fire anyone, but they are hinting that after the dreaded 2015 you may not have a legal leg to stand on in certain situations. All a lawyer has to do is point at the consensus model and say, "It says right here that your training as an acute care NP would not fully prepare you to care for patients in a primary care setting. You didn't certify as and FNP, yet you took care of Mr. Doe in Anytown Family Practice. How can that not be malpractice?...Thank you very much, Mr. Doe here is your $$$$$ check."
APN Scope of Practice « Council for Ohio Health Care Advocacy