Can FNPs Work in Hospital and Specialty Settings?

Ahhh...the age old question. Are family nurse practitioners allowed to work in the hospital setting? The scope of practice for FNPs is a big gray area and one that's often subject to debate. When it comes to accepting a position, if you're an FNP, can you sign on with a hospital?

As a family nurse practitioner employed in the emergency department this is a question I've thought a lot about and done some significant research around. To start off, I'll say that there's no straight answer to this question as the rules and regulations for nurse practitioner practice are still developing. Scope of practice as it relates to family nurse practitioners is a major gray area. In fact, as I'll discuss below, only one state board of nursing has addressed the issue with meaningful specificity. This problem is also not unique to NPs. Many family practice physicians, for example, are employed in emergency departments creating questions and dissention in the MD community

If you're grappling with the question 'Are FNPs allowed to work in the hospital setting?', here are some F.A.Q. to help. 

Why isn't there a straight answer to this question?

As NPs we train in broader specialties than those of physicians such as 'family' and 'acute care' rather than specialty specific like 'cardiology and 'urology'. So, this leads to confusion. In a cardiology practice, for example, are family NPs, acute care NPs, or adult geriatric NPs best suited to work with these patients? What about if the cardiology practice treats patients in both outpatient and inpatient settings? Family nurse practitioners do have a foundation in cardiology even though their education isn't centered around treating patients in the inpatient setting. When it comes to this question, the answer is usually that any of these NP specialties or in the hospital setting are well positioned to care for patients in the specialty or hospital setting provided that they have sufficient on the job training.

Practicing in an ICU or critical care unit may be seen a bit differently than in a specialty or in the emergency department where there is more primary care crossover. If you work in a truly acute setting, you may be best positioned to attain an additional certification as an acute care NP even though this isn't specified by law as we'll discuss below. But, it's probably best practice in case your actions are ever called into question. 

What do scope of practice laws say?

The way nurse practitioners are allowed to practice depends on a set of laws called 'scope of practice laws'. These sets of rules and regulations vary by state. Overall, they are vary vague and say things along the lines of 'nurse practitioners are permitted to diagnose patients and order diagnostic tests'. In the overwhelming majority of cases, they do not say specifically which tests NPs are allowed to order, which procedures they are allowed to perform, or where nurse practitioners are allowed to work (one common exception is with cosmetic procedures). 

While scope of practice laws don't give the specifics we type-A's so desperately crave (just give me a straight answer, pleassse!), they do share some guidance. In most cases, two conditions need to be met for NPs to be practicing in a way that's consistent with their state's scope of practice guidelines: 

1. The NP performing the task is properly trained

2. The activity is within the scope of practice of the individual performing the task (even if scope of practice laws give only a generic framework)

This helps answer our question. If you're an FNP working in the inpatient setting and make sure you're compliant with physician supervisory and prescribing requirements based on laws in your state, you can likely place a checkmark by #2. As far as #1, you must make sure that if you're performing a skill outside of the training you attained as part of your NP program, that you seek proper education on the job. Learning new skills in practice is part of working in healthcare (and really in any profession). Given how high the stakes are in patient care, ensure that you have the proper training and supervision before moving forward. 

Here's an example. If you're an FNP working in the emergency department, part of your job will be suturing lacerations. Suturing is 100% within an NP's scope of practice so you're good to go there. But, you may not have learned how to suture in school. You'll need to get an experienced colleague or supervising physician to train you and likely observe your suturing skills a few times before you're proficient with the skill.

Who regulates scope of practice?

The Board of Nursing for your state regulates nurse practitioner practice and makes sure NPs are practicing within their scope of practice. While laws leave a lot of room for interpretation, regulatory bodies will often publish position statements outlining their perspective. The Georgia Board of Nursing, for example, published a position statement recommending that FNPs working in an acute care setting begin the process of completing the requirements for full certification as Acute Care NPs. The position statement was then retracted in July 2015. Check your state Board of Nursing's position statements to see where they fall on the issue

What does the future hold?

It's likely that we will start to see more specialty tracks emerge for nurse practitioners that clarify scope of practice questions. The recent creation of an emergency NP certification exam is a step in this direction. If you're a family nurse practitioner working in the emergency department, a specialty, or an acute care setting, you can likely continue to practice in your current setting. Most often, as new certifications, specialty tracks and BON recommendations emerge, they leave a path for continued practice for those currently employed to avoid disruption in the field. Stay tuned, however, to scope of practice and BON updates in your area as you may be required to complete continuing education or meet other requirements to continue practicing in your area of expertise. 

Are you a family NP practicing in an acute, inpatient or specialty setting? How do you feel about the scope of practice discussion?

 

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Comments

I work (for 3 years) as a FNP-hospitalist in a tertiary care center. It's only a 250 bed hospital but it's the regional referral center. I learn something new everyday. Yes it can be very stressful. I had about 10 years of critical care/ICU experience in bigger hospitals, but there is a big difference between writing the orders and just carrying out the orders. I've worked with good and bad NPs, and good and bad MDs. I do the same things as the MDs do. Sometimes I'm better than them, sometimes I'm not. But my patient's like me and the nurses love me because I've been at the bedside as a nurse. It's not for everyone, but it is certainly interesting and rewarding if you can handle the intensity. It is certainly different than primary care, not better, not worse. Just different. I like it.

Don Wipf

I am an ER NP, and definitely struggled with my state board regarding my role and scope of practice. I had to send very explicit documentation of my role and expectations prior to starting as I was still in my 2 year supervision.

Susan

This is such a gray area! I have worked with FNPs in an inpatient setting and I could tell you horror stories! But then I have some FNPs that have recent ICU experience as RNs that do just fine. I think it’s time for the NP training to raise the bar to that of the PA training. As an ACNP, I do not need a model focused on the NURSING process beat down my throat! Save that for the BSN and PhD programs. Just my 2 cents!

Scott Franklin