Can a Family Nurse Practitioner Work in the ED or ICU?

Carolyn Buppert, MSN, JD

Disclosures

October 02, 2014

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Question:

Can a family nurse practitioner work in an emergency department or intensive care unit?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

Certification of nurse practitioners (NPs) in acute care is available, so being a family nurse practitioner (FNP), where preparation focuses on primary care, is not the optimal match for emergency department (ED) or intensive care unit (ICU) practice.

The Board of Nursing for each state is the final authority on whether it is within the scope of practice of an FNP to work in acute care and/or intensive care. Boards differ in their policies. One Board said that an FNP (or another type of NP not certified specifically in acute care) may not care for patients on monitors. That would significantly curtail the usefulness of an NP working in an ED or ICU.

Some Boards take no stand on this issue. Other Boards provide decision-making tools to use to determine whether a function or set of functions are appropriately performed by an individual nurse. Questions to be answered include[1]:

  • Did I complete a program that prepared me to see this population of patients?

  • Did this program include supervised clinical and didactic training focusing on this population?

  • Did I complete a program that prepared me for subspecialization? If so, is the patient in question in that category?

  • Do I have the knowledge to differentially diagnose and manage the conditions for which I am seeing this patient?

  • What are the clinical competence/skills required to treat this condition?

  • Have I been trained to differentially diagnose in this type of patient?

  • Did this training include clinical and didactic training?

  • How have I achieved and demonstrated competence?

  • How have I maintained competence?

  • What is the standard of a practitioner in this field, and do I meet it?

  • Do I meet these standards on a limited or broad basis?

  • Have I completed a specialty preceptorship, fellowship, or internship that qualifies me beyond my basic educational training? What are the potential consequences of accepting treatment responsibility for this patient?

  • Am I prepared to accept and manage the consequences of my diagnosis and treatment, or do I have a formally established relationship with a provider who is so trained and immediately available?

  • If I am not the primary care provider, will my provision of care be shared with this person?

  • Is the safety of the patient at acute risk if I do not act?

  • Will the safety of the patient be compromised if I do act?

Here is an additional consideration that deserves thought: If something goes wrong and the FNP working in the ED is sued, the first thing the plaintiff's attorney will ask is, "What qualifies you to provide emergency services?" An NP who is certified in acute care and/or emergency care can point to the certification. An NP certified as an FNP is going to be in a weak position, because FNP programs do not prepare NPs to provide services in EDs.

There are plenty of FNPs working in EDs and in ICUs. Because acute care certification is a relatively recent development, in years past, there was no applicable certification, and all of the NPs working in hospitals, ICUs, and EDs were adult NPs, pediatric NPs, or FNPs. All were educated in primary care. Many had critical care experience as registered nurses.

An FNP who has been practicing in an ED or ICU since 1990 will be in a better position to defend his or her competence and lack of the appropriate credential than a newer FNP. Critical care experience as a registered nurse may be a practical asset, but it does not substitute for didactic learning, supervised clinical practice, evaluation by a preceptor, and successful completion of a certification examination. Given that acute care certification has been available for 20 years, any new NP would be wise to obtain that education and certification, if working in the ICU and/or ED setting is the goal. Only if the state Board of Nursing gives the go-ahead for FNPs to practice in EDs and ICUs should an FNP without additional certification feel comfortable practicing in critical care.

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