Doing the Work of Two: Should I Be Expected to Function as Both RN and APRN?

Carolyn Buppert, MSN, JD

Disclosures

August 17, 2016

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Question

Should I Be Expected to Function as Both RN and APRN?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

An advanced practice registered nurse (APRN) wants to know whether she should be expected to function both as APRN and registered nurse (RN) at the clinic where she works:

I am an APRN, but my employer views me and my colleague APRNs as staff members who can perform a nurse's job as well as our APRN jobs. That means that most days we may not have a nurse helping us, and we essentially are running the clinic area alone. Is this good practice to have one professional doing both jobs? I worry about being liable and negligent trying to do both jobs at once.

Legally, you can do both. So that means that this is an issue of patient safety and also an issue of personnel management. I can envision two ends of a spectrum. On one end, the APRN is being spread too thin, time-wise, and advanced practice is suffering because of the RN-practice duties that need attention. That could be a risk management problem, because the APRN could overlook patient follow-up or fail to ask a pertinent question of a patient, resulting in a missed diagnosis and a lawsuit against the APRN and employer. One the other end, if the clinic has just a few patients on any given day, it makes sense, personnel-wise, to have an APRN run the clinic alone. This arrangement could be safe.

One way to present the issue to management is to track how many days each week you are scheduled to see more than a threshold number of patients. For discussion purposes, let's set the threshold at 15 established patients in adult internal medicine in an 8-hour day. The number could be higher – 20 patients per day — for pediatrics, some family practices, and some practices where the level of visit is current procedural terminology (CPT) codes 99212 to 99213. The number could be lower for new patients and if the patients require evaluation and management at the higher CPT levels.

If the schedule is for more patients than the threshold number, then you should have a fairly strong argument that you need an assistant. Whether that assistant is RN level or a medical assistant depends on the level of service needed. You might check with colleagues at other clinics to determine their threshold for having one or more assistants.

If the number of patients seen each day is below threshold, then your argument for having an RN with you is weaker. However, in that case, you might keep track of the time you spend on various services and tasks for several days, and use those data to argue that a different staffing strategy is called for. For example, perhaps clinic hours could be reduced and perhaps your advanced practice services could be employed better in another clinic. It makes little sense for an employer to pay APRN salary for RN or assistant duties, so presumably your employer would want to have the most efficient staffing mix. And, your employer also should be cognizant of the risks associated with spreading an APRN too thin.

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