Scope of Practice - Acute NP vs FNP

[ICURNPA92]

Hello everyone, I have heard so many different things from others based on the CRNP role specialties. Everything I'm reading seems outdated and Pennsylvania isn't specific in its scope of practice about the differences between each specialty.

Could anyone clarify the roles, similarities, and differences between the two.

Can an Acute NP work outside the hospital?

Can a FNP work in the hospital as a hospitalist, in the ER, or ICU?

[Jules A, MSN]

Great timing. Carolyn Buppert's tip of the month is about practicing within your credentials. I enjoy her stuff and she cites a case where a FNP is dealing in psych poly pharm which goes bad. It is likely this will continue to increase with all the new grad FNPs hit the streets with the mantra that FNPs can do anything. Thankfully the university where I got my FNP told us at the first class that if we want to work in acute care we are in the wrong program. My understanding is it is dependent on your state's board and your training however regardless if there is a certification offered such as psych or ED and you don't have it I don't think it will look good in court.

This months tip is titled: Match your practice to your credentials

Her medscape article on same topic: Can a family nurse practitioner work in an emergency department or intensive care unit

[ICURNPA92]

I can't find it on any government or state nursing websites the distinct difference in scope of practice and where you can and can't practice as an FNP or ACNP

[Corey Narry, MSN, RN, NP]

You may find that information difficult to look up. Majority of states (such as PA) have general statements regarding scope of practice that uses language applicable to the NP role regardless of setting or patient-specific healthcare conditions. For instance, many states use the words "prescribing", "diagnosis", "treating", etc which do apply to all NP's regardless of specialty.

There are a few states that took the effort to explain what is specific to the NP role such as Texas for instance which clarifies that:

- formal training in the NP role is the foundation of your scope as an NP

- there are limits to expanding one's scope of practice without completing formal NP training

- NP's can not change their scope through experience or continuing nursing education as these may only be changed through formal education

See: Texas Board of Nursing - Practice - APRN Scope of Practice

What that is alluding to is the fact that NP education have now evolved to our existing Consensus Model-based NP specializations that have specific limitations between primary care and acute care, adult-gerontology vs pediatric vs family, as well as specific tracks in mental health, women's health, and neonatal care. It does clarify the fact that nursing experience prior to NP education does not determine scope of practice.

Some national organizations such as AACN have official documents that describe specific scope of practice limitations such as this particular one for ACNP's: https://www.aacn.org/nursing-excellence/standards/aacn-scope-and-standards-for-acute-care-nurse-practitioner-practice (you will need a log in to see it).

So what does this mean to each individual NP? In the absence of state language describing scope of practice, national standards can be invoked and the trend is going in the direction of making sure we NP's practice within the boundaries of our training. It is wise to do so for risk management reasons - in the event of litigation, prosecutors would have a field day knowing that an NP involved in a malpractice suit was not formally trained in the role they were performing.

And as Jules already pointed out, Carolyn Buppert, a legal expert and a trained NP herself, offers important guidelines for NP's to think about when performing our role: Medscape: Medscape Access (log in required).

[Dodongo, APRN, NP]

I can say that in Pittsburgh, the hospital systems are showing great preference for ACNPs in the hospital.

[SopranoKris, MSN, RN, NP]

It really depends on your state and the hospital's preference within that state. I'm in MI and FNPs can be hospitalists. Of course, the hospitals prefer that your nursing experience is in acute care, particularly ICU or ER. If I want to work in my hospital's ER, they prefer either dual FNP/ACNP certification (so you can see pts of all ages) or at least have the FNP with a minimum 2 years experience in ICU or ER. The trauma unit wants ACNPs only, understandably.

Other hospitals I've found in different states want the ACNP to work the units or ER. I certainly wish it was a more cut & dry answer. I would love it if our training was more along the lines of PA, where we get exposure to everything and can then settle in on a specialty, instead of having to choose one up front. There are pros & cons to both. Some people don't want to bother with specialties that don't interest them, which is understandable. I chose FNP because I felt it gave me a broader scope and more employment potential, plus I'm already an ICU nurse.

[Dodongo, APRN, NP]

It really depends on your state and the hospital's preference within that state. I'm in MI and FNPs can be hospitalists. Of course, the hospitals prefer that your nursing experience is in acute care, particularly ICU or ER. If I want to work in my hospital's ER, they prefer either dual FNP/ACNP certification (so you can see pts of all ages) or at least have the FNP with a minimum 2 years experience in ICU or ER. The trauma unit wants ACNPs only, understandably.

Other hospitals I've found in different states want the ACNP to work the units or ER. I certainly wish it was a more cut & dry answer. I would love it if our training was more along the lines of PA, where we get exposure to everything and can then settle in on a specialty, instead of having to choose one up front. There are pros & cons to both. Some people don't want to bother with specialties that don't interest them, which is understandable. I chose FNP because I felt it gave me a broader scope and more employment potential, plus I'm already an ICU nurse.

The grass isn't always greener. Yes, PAs are trained as generalists, but they also have recertification examinations that cover the full spectrum of medicine. So a PA working in peds must re-learn gero, and one working with adults in ortho must cover OB. Their license and job depend on it. It's stressful to say the least. Physicians and NPs don't have to do this because we "specialize".

And nurses choosing a NP program need to have a bit of forethought. Many do not think that FNPs will continue being allowed to practice in any setting they so choose with the push for full scope of practice/independence, the consensus model gaining traction and more specialized NP programs expanding and cropping up in each state. Many of the larger hospitals systems are preferentially hiring ACNPs for inpatient positions, regardless of what state BON say or do not say about NP scope of practice. Certain specialties have strong preferences. If I go down to the local women's hospital or OB office in my area it is almost all WHNPs or CNMs. Local hospitals are full of ACNPs. The children's hospital is full of PNPs. Outpatient offices/UC are staffed by FNPs.

All I'm saying is try to not be myopic and put some thought into how the landscape will be in 10 years or more, rather than how it is right now.