States restricting FNPs rounding on inpatients

[Adenium]

Hi all,

I've been following this forum for a couple years now, since I started contemplating a career change into nursing. Recently, making my decision on a Master's program, I've even been reading back through all the old threads to help solidify my decision. Many hours of NP land!!

Some things are still clear as mud, mainly how much choosing FNP/ANP will restrict someone hoping to mainly work in an outpatient specialty office but who MAY be asked to round on inpatients. In my area I'll be OK, but I'm not sure where I'll end up living later in life. Not too excited about going back for a post-master's while working a full-time NP job, unless I really have to. I'm hoping to do outpt cardiology, but have applied for the FNP so I can have other options when looking for jobs.

I know from the zillion posts that Texas is really cracking down on FNPs for this. I'm in CT, and most of the cardiology office NPs I've seen are FNP/ANP. Many are hospitalists. Some perform the ACNP function in the ICU. Some are ACNPs and we do have local programs producing them so it's not a shortage issue for the hospitals. What's more, in asking these ANP/FNPs they'd never heard of all these restrictions going on in other areas.

My question is, since many people just write in "well, in my area they're starting to come down on this...or I've heard of this being an issue in some places....."

WHERE are these geographical areas other than Texas? Where is the FNP/ANP being restricted and to what extent?

1) Sees outpatient and inpatient

2) Sees outpatients ONLY

3) Not only restricted to outpatients, but only general PRIMARY care outpatients, no outpatient specialty offices

A lot of NPs have written that they have training to specialize, whereas FNP/ANP don't. But if you do clinical rotations and take a job doing similar, aren't you covered? Are people talking about specializing inside the hospital, or outside?

Sorry it's long-winded. It kills me that nursing is so all over the place and we have to guess on the best path, but given where I am I'm not switching to PA instead. Onward and upward! Thanks for all your help in the many threads already touching on this as well as what anyone adds in here!

[Adenium]

in my part of the world, FNP is restricted to family practice either hospital based(inpatients) or outpatient clinics. Specialty areas are the scope of the Adult Nurse Practitioner which covers every specialty(excluding kids and babes)

I met the criteria for both licences so can work in either family practice or a specialty area.

However, I would never apply to an area that I am not familiar with or have the NP skillset: ICU, CCU, ortho, renal etc.

I am quite comfortable working adult hem/onc, adult internal medicine inpatient and adult family practice inpatient. Since I have never worked full scope family medicine in a clinic...that is an area that I would not choose to work in unless I had a burning need and the time to get clinically updated.

So it's considered family practice while they round on inpatients? I haven't heard of family practice being referred to as taking care of inpatients before....just that sometimes FNPs are hired as hospitalists, particularly in areas without ACNP programs.

Really I have no big problem with being shut out of the hospital with an FNP certification. I just wish there were greater clarification on outpatient specialty. I still hear a lot of conflicting information as to whether this is the domain of ANP/FNP/ACNP, from this board and from practitioners around me. I guess because it really does vary geographically - even within a state. However, given that I'm enrolled as FNP I shall carry on and add to it later if needed. Hope I'm making the right choice, though, so I don't end up with a saga as long as Trauma's!

[Corey Narry, MSN, RN, NP]

So it's considered family practice while they round on inpatients? I haven't heard of family practice being referred to as taking care of inpatients before....just that sometimes FNPs are hired as hospitalists, particularly in areas without ACNP programs.

Really I have no big problem with being shut out of the hospital with an FNP certification. I just wish there were greater clarification on outpatient specialty. I still hear a lot of conflicting information as to whether this is the domain of ANP/FNP/ACNP, from this board and from practitioners around me. I guess because it really does vary geographically - even within a state. However, given that I'm enrolled as FNP I shall carry on and add to it later if needed. Hope I'm making the right choice, though, so I don't end up with a saga as long as Trauma's!

It really depends on a lot of variables. As far as physicians go, there are hospitals in the community that allow FP attendings privileges to manage their own patients when they are hospitalized even if it becomes an ICU admission. In big academic medical centers, you won't see that happening at all because there are hospitalists and intensivists on the staff roster whose practice is dedicated solely to the management of the hospitalized patient in the acute care units (for hospitalists) and critical care units (for intensivists). In these places, FP physicians only see patients in the primary care setting. And just to further clarify, hospitalists are typically trained in IM (adults only) though some are trained in a combined IM and Peds residency and can care for both adults and children. I've never met an FP physician who is also a hospitalist unless they also trained in IM or peds. In the absence of state reg that limit FNP's from practicing in the in-patient setting, the medical staff credentialing policy will determine what is allowed for those NP's trained in the primary care fields.

You will really have to look into your state BON for guidance. Some states are apparently more explicit such as Texas and Maryland. Arizona, which happens to be an independent practice state has this to say on the matter: http://www.azbn.gov/documents/ap/RNP%20Practicing%20in%20Acute%20Care%20Setting-Final%20WHITE%20PAPER%20Oct%202009.pdf

[Adenium]

I know. You wouldn't believe how little the BON could offer help. They really don't seem to care one way or another here. Then I tried to contact the credentialing folks at the hospital - got run in circles and no one seemed to know what I was talking about. I wanted to send them all to this forum.

[bsnanat2]

In your research of this, be sure to ask your state BON if they intend to adopt the NCSBN Consensus Model. Many states are and the hope is 2015 for adoption. So many focus on the 2015 DNP proposal that they miss that the Consensus Model is a much more real issue. This would make APRN practice and regulations much more uniform nationally. This model specifies that the acuity of the patient is the deciding factor, not the setting. Under the model, FNP's would not be allowed to do things like ICU unless they obtained ACNP cert also. As society becomes more litigious, some of these practice situations will become much more dangerous to be in. I'm afraid that a primary care trained provider in ICU will become legally indefensible.

[Adenium]

Right. And I don't want to be in ICU. I want to be in specialty outpatient, which seems to have no clear answer. Perhaps in hospital rounds for cardiology, etc., but not in an ICU or hospitalist position.

I wonder if my BON is even familiar with the consensus model.

[bsnanat2]

I'm sure your state BON is familiar with the Consensus Model. The problem is usually in getting to (on the phone) someone who has a real working knowledge of things and is not just guarding the phone lines. The Consensus Model is one of the few things that Nursing leadership has gotten right. The specialty outpatient question is answered by the Consensus Model based on the acuity of the patient. Critical, unstable acute = Acute Care NP, not FNP. Can it be handled in a clinic or is the patient basically stable? FNP OK. As there should be, the Consensus Model allows for some overlap and doesn't spell out every situation in detail. The Consensus Model is a good plan to work from. The problem will come when folks want to do something the model clearly doesn't allow for (for example, FNP in ICU). When adopted, it'll make life easier for all APRN's nationwide, but will certainly make things more difficult for some individuals. At that time either new job decisions will have to be made or new credentials will have to be obtained. The only way to truly be able to do it all is to do it all (get all the certs).

[bsnanat2]

For the record, I'm not against FNP's in ICU's or other settings. One of the issues in nursing is the tremendous variance in programs. Some programs provide a great base for any specialty while others seem to provide the minimum needed to prepare someone to pass the licensing exam. That being said, nursing's creation of all these individual certs has backed us into a corner. It would have been wiser to simply expand on FNP programs and make them longer to include acute care, more peds and geriatrics. That would a BSN to DNP worth having. Then you could do it all. Since that ship has sailed, we're stuck with the current hodge-podge of certs and turf battles.

[traumaRUs, MSN, APRN]

Hmmm - I wonder how this work in my practice: I'm in nephrology and most of my pts during the week are outpt dialysis pts. We consider them stable but they code often and can become unstable quickly. Then, when I'm on call, I round on inpt nephrology pts with all kinds of complaints and many are in the ICU.

My education is adult health CNS and peds CNS and I've had education in acute care, chronic care, geriatric and pediatric. I think (and hope) I would be covered.

[bsnanat2]

Hmmm - I wonder how this work in my practice: I'm in nephrology and most of my pts during the week are outpt dialysis pts. We consider them stable but they code often and can become unstable quickly. Then, when I'm on call, I round on inpt nephrology pts with all kinds of complaints and many are in the ICU.

My education is adult health CNS and peds CNS and I've had education in acute care, chronic care, geriatric and pediatric. I think (and hope) I would be covered.

That's really why CNS is the "sweet spot" of the Consensus Model. There is a nice little footnote that says that a CNS covers the continuum from primary care to acute care. That's one of the major reasons I'm considering CNS.

[Corey Narry, MSN, RN, NP]

That's really why CNS is the "sweet spot" of the Consensus Model. There is a nice little footnote that says that a CNS covers the continuum from primary care to acute care. That's one of the major reasons I'm considering CNS.

Not to play devil's advocate here but the roadblock for making the CNS the "sweet spot" in terms of interpretation the Consensus Model is the fact that "prescriptive authority" was not clearly stated in the CNS role. The model does state that CNS's diagnose and treat health/illness states but if you look at how the model described the NP, it goes on to state the NP role inlcudes:

"ordering, performing, supervising, and interpreting laboratory and imaging studies; prescribing medication and durable medical equipment; and making appropriate referrals for patients and families"

The state BON's are clearly on the Consensus Model bandwagon since NCSBN is one of the original authors of the document. However, the model, at least to me, does not force states to allow CNS's to have prescriptive authority.

Source: http://www.aacn.nche.edu/education/pdf/APRNReport.pdf

[bsnanat2]

Not to play devil's advocate here but the roadblock for making the CNS the "sweet spot" in terms of interpretation the Consensus Model is the fact that "prescriptive authority" was not clearly stated in the CNS role. The model does state that CNS's diagnose and treat health/illness states but if you look at how the model described the NP, it goes on to state the NP role inlcudes:

"ordering, performing, supervising, and interpreting laboratory and imaging studies; prescribing medication and durable medical equipment; and making appropriate referrals for patients and families"

The state BON's are clearly on the Consensus Model bandwagon since NCSBN is one of the original authors of the document. However, the model, at least to me, does not force states to allow CNS's to have prescriptive authority.

Source: http://www.aacn.nche.edu/education/pdf/APRNReport.pdf

Well, that is the whole purpose of a consensus model, to make things uniform. Georgia would only give psych CNS's prescriptive authority until recently, but in preparation for adopting the Model, all CNS's now have that authority. So, if states adopt the Model, they adopt CNS's as outlined in the Model. That conversely means that CNS's that don't meet the educational requirements laid out in the Model won't be able to continue in that role or use that title in those states.

[bsnanat2]

Not to play devil's advocate here but the roadblock for making the CNS the "sweet spot" in terms of interpretation the Consensus Model is the fact that "prescriptive authority" was not clearly stated in the CNS role. The model does state that CNS's diagnose and treat health/illness states but if you look at how the model described the NP, it goes on to state the NP role inlcudes:

"ordering, performing, supervising, and interpreting laboratory and imaging studies; prescribing medication and durable medical equipment; and making appropriate referrals for patients and families"

The state BON's are clearly on the Consensus Model bandwagon since NCSBN is one of the original authors of the document. However, the model, at least to me, does not force states to allow CNS's to have prescriptive authority.

Source: http://www.aacn.nche.edu/education/pdf/APRNReport.pdf

Well, that is the whole purpose of a consensus model, to make things uniform. Georgia would only give psych CNS's prescriptive authority until recently, but in preparation for adopting the Model, all CNS's now have that authority. So, if states adopt the Model, they adopt CNS's as outlined in the Model (as Advance Practice Nurses). That conversely means that CNS's that don't meet the educational requirements laid out in the Model won't be able to continue in that role or use that title in those states.