The hospitalist dilemma

[sauce]

There seem to be many questions in regards to if FNP can work in an inpatient role. This is especially interesting in regards to if they can work in an ICU and provide ICU level care to patients. While I am far from an expert in anything in life, I would like to provide a post for some discussion since I have read quite a few of these posts with the above stated question as the main focus.

I currently work in a medium sized rural facility. Around 360 Beds. We have two ICU. One is a CV unit, the other is the general run of the mill ICU for everything non-cardiac related. Most of our work is done in the regular ICU, since the cardiologist manage most of the stuff in their unit, but we do get consulted for many issues in their CVU, but this is for another topic.

As an FNP hospitalist” or whatever you want to call it, we do only inpatient care. This ranges from your simple chest pain rule outs that probably didn't need to be admitted, all the way down to patients with septic shock, on the vent, surgical icu patients, etc. Usually we do the admitting at night. Our shift is from 6 pm to 6 am. We are usually the only provider in the hospital from around 11-5 am, unless there is an emergency surgery, stat cath, or a central line needs placed in the er or on the floor. This excludes the ER physician, who runs a fair share of the codes at night, but not all.

We admit, provide orders, and call the shots on our ICU patients. Of course we have pulmonology back up for complicated vents and surgeons for surgical related problems. We also have the regular sub specialties including cardiology, nephrology, ortho, etc. But they are all sleeping, and have all the local clinic group patients to care for also. Us as the hospital group also get the benefit of specialists, but we are there, so we are usually the first line for non-obvious problems that would go to the specialist.

We do everything except intubate or put in lines.

Were we trained for this in fnp school. Nope.

Did we work as an ICU nurse before this. I didint, the other guy did.

Do we manage, Yup.

Are we smarter than the average person. Nope.

How do we do it?

We got trained for a few months after school and picked up some high quality texts off of amazon.

Should we have been ACNP- probably, but we didn't know we wanted to do this in school. would their be a benefit in going back for an ACNP cert. Probably not much besides learning to intubate better and put in lines, chest tubes and such.

But we can take seminars or train with the physicians at the hospital for this.

If i knew i wanted to do this forever I would have gotten a critical care program instead, but we didin't, but we were needed.

Do we feel competent in our position- Yes.

Is there more we could learn- of course, but our current knowledge base gets us through the night. Maybe if we were on the critical care team it would be different, but again, at night we are the critical care team. If the care of the patient was in our hands 24.7 this might be a different story, but in our case, the FNP cert, along with some extra training and self-directed study has gotten us a long way.

Feel free to comment with questions or responses,

Thanks!

[Dranger]

I think this situation fall more under the experience spectrum. Can FNPs work inpatient or even ICU? Yes. Should they? Probably not. With the consensus model expectations will change as will hiring preferences in a hospital. There are NP specialties for a reason, would you have a ACNP or ANP working a women's health or OB clinic? No. Could they? Possibly. We all know FNPs see the lifespan spectrum of patients but shouldn't there be an ethical line especially with new NPs to give way to appropriate specialties? ACNPs are solely acute and specialty care and thus should be the NP model of a hospitalist. I don't understand why this simple notion ruffles so many feathers on here. People seem to feel that with specialty such as FNP that they should be a candidate for every NP position. Just doesn't make sense to me.

While I think you are probably an excellent provider and commend you for the self-learning, don't you think a few Amazon books and OJT seems a little lacking for most people trying to run an ICU? Personally, I don't think it would fly where I work (pulmonologist on call admits every vented patient except stable ODs or post-op vents) but I understand you are located in a high need rural area. I mean how would the general public react to a cardiologist or other specialty doc doing the same thing to get up to snuff in a particular area rather than a residency.

I think your situation is pretty specific but as for a dilemma I think the consensus model fairly acute. If you want to go acute care go ACNP or a post-cert for FNPs wanting to transition. Ethically I think going FNP for practicality but expecting to work acute care without any real formal training in clinicals (or at least majority dedicated hours) is not the correct answer.

[traumaRUs, MSN, APRN]

I have copied and pasted from one of my previous posts as I have looked up the consensus model and this is what it says:

With the APRN Consensus Model implementation date of 2015, here is what the AACN says about Adult-Gero ACNP:

The patient population of the adult-gerontology acute care NP practice includes the entire spectrum of adults including young adults, adults andolder adults. The adult–gerontology ACNP provides care to patients who are characterized as physiologically unstable, technologicallydependent, and/or are highly vulnerable to complications” (AACN Scope and Standards, 2006, p 9). These patients may be encountered acrossthe continuum of care settings and require frequent monitoring and intervention. The role encompasses the provision of a spectrum of careranging from disease prevention to acute and critical care management to stabilize the patient's condition, prevent complications, restoremaximum health and/or provide palliative care” (AACN p. 10). It is assumed that preparation of the graduate with these competencies unlessotherwise specified includes preparation across the entire adult-older adult age spectrum. It also is assumed that the graduate is prepared toimplement the full scope of the adult-gerontology acute care NP role.

http://www.aacn.nche.edu/geriatric-n...mpetencies.pdf

I have bolded the pertinent portion about settings where an AGACNP can practice.

From the National Organization of NP Faculties comes this:

A fundamental premise of the Consensus Model is that NP competencies are not settingspecific.Historically, the acute care NP (ACNP) practiced predominantly in the hospital and theprimary care NP (PCNP) practiced within a community setting. These setting boundaries oftenoverlap, however. It is inappropriate and restrictive to regulate acute and primary care scopeand practice based on settings but instead regulation should be based on educationalpreparation and scope of practice. Formal NP educational programs prepare adultgerontologicaland pediatric NPs to provide either primary care or acute care services

http://c.ymcdn.com/sites/www.nonpf.o...cticeFINAL.pdf

So, while some individual facilities may request/require ACNP for in-hospital positions, it is not required by our credentialing organization.

[TammyG]

FNPs served as hospitalists for years very successfully prior to implementation of the consensus model. Although I have noticed an increase in employment requirements for ACNP grads to fill hospitalist positions, there are simply not enough grads to go around, and those grads tend to be new and inexperienced. I predict that FNPs (and other non-ACNP grads) will be serving as hospitalists for many years to come.

[elkpark]

Lots of things "fly" in rural areas with limited availability of specialists (limited availability of providers, period). Does that mean it's a good idea? No. Does that mean people should be doing it everywhere? No. Do I believe clients deserve better? Yes.

[sauce]

I do agree with dranger, as we probably shouldn't run the ICU. We don't really run it, like i said we have pulmonologists and can call them at any time, we usually just don't have to.

Its not as bad as people think it is.

[Jules A, MSN]

I do agree with dranger, as we probably shouldn't run the ICU. We don't really run it, like i said we have pulmonologists and can call them at any time, we usually just don't have to.

Its not as bad as people think it is.

Although I totally admire your cojones and commend you for doing what I perceive to be a very complicated and difficult job I'm not sure I would be comfortable doing it without the certification that is available. If it weren't available no biggie but it is.

I do think in the future things will change and more restrictions will be in place to ensure specialties are cared for by professionals who have had a formal education in the area. My guess is that it its all well and good until someone loses an eye ie. the first time something goes to court my concern would be that you will be thrown under the bus toot-sweet.

[Lajimolala, BSN, RN, NP]

Just wanted chime in that this is true in rural areas across professions. A family physician I worked with has a friend from way back in medical school who is also a family physician. But this guy works in a small rural town in the Southwest, and also delivers babies--- as a family physician! So, it's not just a nursing thing.

[Jules A, MSN]

Just wanted chime in that this is true in rural areas across professions. A family physician I worked with has a friend from way back in medical school who is also a family physician. But this guy works in a small rural town in the Southwest, and also delivers babies--- as a family physician! So, it's not just a nursing thing.

Definitely but that doesn't make it a sound practice and my guess is he had a L&D rotation so while not my first choice if I personally were birthing a baby a MD did in fact have formal training which NPs have not had. The other thing is imo in court they will come after a nurse way quicker than a physician.

PS. Great thread OP.

[Momma1RN, MSN, RN, APRN]

We've got an FNP on staff within our hospitalist group and she is fantastic. Very knowledgable and seems more competent than some of the docs. That being said she doesn't work nights and doesn't cover our ICU patients. During the day we have intensivist hospitalists and at night a regular hospitalist (the only one for the hospital at night) covering ICU.

[Lajimolala, BSN, RN, NP]

Definitely but that doesn't make it a sound practice and my guess is he had a L&D rotation so while not my first choice if I personally were birthing a baby a MD did in fact have formal training which NPs have not had. The other thing is imo in court they will come after a nurse way quicker than a physician.

PS. Great thread OP.

Jules,

Thanks for your response but I never meant to make an argument for sound practice. I meant to add to that it doesn't always apply only to nurses. Of course most people, I would hope anyway, would want to give birth with someone with formal training. My whole point was to add to elkpark's comment that in rural areas, a lot more things "fly."

[BostonFNP, APRN]

MD did in fact have formal training which NPs have not had.

If I were birthing a baby I would actually prefer an NP with L&D experience as an RN over an MD that had a 6 week rotation.

But the point is, there are some FNPs with appropriate ICU experience to safely function in that role, especially with support from experienced ICU RNs. There are many without and that is where the ethical boundary lies: if you don't have the education and experience/training/support you should not be practicing in that role.

Sent from my iPhone.