Role & Scope of Practice of a Family Nurse Practitioner

Family Nurse Practitioner

Family nurse practitioners (FNPs) are graduate-educated, nationally-certified and state licensed advanced practice registered nurses (APRNs) who care for medically stable patients across the lifespan, from infants to geriatric patients. “Family” in this case describes the NP’s chosen patient population focus and denotes national certification through one of two certifying bodies that certify NPs as having the specialized skills necessary to work with this patient group: the American Nurses Credentialing Center (AACN) or the American Academy of Nurse Practitioners (AANP).

Just like a primary care physician, FNPs provide continuous, comprehensive care through disease management, health promotion, health education, and preventative health services.

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They are qualified to …

  • Manage chronic conditions, such as hypertension and diabetes
  • Oversee the health and wellness of women, including providing preconception and prenatal care
  • Provide health and wellness care to infants and children
  • Treat minor acute injuries
  • Provide episodic care for acute illnesses in all ages

FNPs often co-manage the conditions of their patients with other specialists and provide case management for long-term illnesses and conditions.

Their job duties include diagnosing illnesses and conditions, ordering and interpreting diagnostic tests, conducting examinations, providing counseling, and prescribing medications in many cases.

FNPs may also earn additional specialty certification to further specialize in areas like cardiology, women’s health, and neurology, among many others.

Because of their ability to work with a broad patient population across all age ranges, life stages and genders, FNPs are found in an equally diverse number of settings – from independent private practices with other NPs, physician’s offices and major hospitals, to schools, state and local health departments, community clinics and other ambulatory care facilities.

In some areas of the country, particularly in rural and urban areas where physician shortages are persistent and prevalent, FNPs are the sole healthcare providers in nurse practitioner-led clinics. They provide much-needed services to underserved populations that would otherwise have very limited access to preventative care, or healthcare of any kind. It’s the very fact that FNPs are able to practice autonomously and have been educated at the post-bachelor’s level in health diagnosis and assessment, physiology and pharmacology that allows them to serve in a primary care role. This is, perhaps, the most defining characteristic of an FNP’s scope of practice.

No uniform model of regulation for NPs exists. Therefore, the FNP’s scope of practice is ultimately determined by the state in which they hold their license. And, as is common with state-regulated professions, rules and regulations for NPs often vary from one state to the next.

Still, organizations including the American Association of Nurse Practitioners (AANP), have taken a position on the scope of practice for nurse practitioners, stressing the unique level of accountability and responsibility they bear. The AANP describes NPs as being accountable by way of peer review, an evaluation of clinical outcomes of patients in their care and continued professional development. They have a unique responsibility to the needs of the public and the healthcare system and are looked upon as mentors, leaders and educators who participate in patient advocacy and the advancement of health policy.

 

Scope of Practice is Determined by State Boards of Nursing: Independent Practice and Prescriptive Authority

Under the guidance and leadership of the National Council of State Boards of Nursing (NCSBN), dozens of the most influential nursing organizations, from APRN certification agencies to professional advocacy groups working at the state and national levels continue to fight for legislative reform that would allow NPs to be able to practice and prescribe independently to the full extent of their knowledge and training without the need to maintain an oversight agreement with a physician. This has become even more important as physician shortages loom.

According to the American Medical Colleges (AAMC), physicians shortages may reach between 46,000 and 90,000 by 2025. Within that shortfall, it is projected that between 12,500 and 31,100 will be in primary care.

Many state boards of nursing like Alaska, Hawaii, and Washington State grant NPs full practice authority. This means that NPs in the state can practice and prescribe medications without any physician collaboration or oversight. As of 2017, 22 states and Washington D.C. have granted NPs full practice authority:

  • Alaska
  • Arizona
  • Colorado
  • Connecticut
  • District of Columbia
  • Hawaii
  • Idaho
  • Iowa
  • Maine
  • Maryland
  • Minnesota
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Mexico
  • North Dakota
  • Oregon
  • Rhode Island
  • South Dakota
  • Vermont
  • Washington
  • Wyoming

In other states, such as New York, Pennsylvania, and Ohio, NPs can practice independently but are required to enter into a collaborative physician agreement. Some states, such as California, Texas, and Florida, still require NPs to practice under physician supervision or delegation.

While all state codes now recognize NPs are primary care providers, in many states, they do not enjoy the same rights as physicians. For example, in California, NPs must be supervised by physicians. And in some cases, physicians must sign NP charts to qualify for insurance reimbursement. NPs in California must also enter into a collaborative agreement with a physician or have direct physician supervision/delegation in order to prescribe drugs.

Other states are much more progressive, giving NPs the latitude they need to practice autonomously. For example, in Colorado, NPs can prescribe medications without Board of Medicine or physician oversight. As of 2017, 14 states and Washington D.C. allow NPs to prescribe medications without physician or Board oversight:

  • North Dakota
  • Wyoming
  • Arkansas
  • Idaho
  • Montana
  • Oregon
  • Washington
  • Hawaii
  • Arizona
  • New Mexico
  • District of Columbia
  • New Hampshire
  • Rhode Island
  • Iowa
  • New York

Other variations exist, too. For example, in Washington, NPs enjoy most of the same privileges as physicians, which include admitting, managing, and discharging patients from hospitals and other healthcare facilities. At the other end of the spectrum, Alabama is so restrictive that NPs must practice at least 10 percent of the time alongside their collaborating physician.

In some states, the scope of practice for NPs is clear and detailed, while in others, much is left to interpretation, largely because it is not much different than the scope of practice of an RN.

For example, Arizona provides a detailed list of NP rights:

  • Examine patients and establish medical diagnoses by client history, physical exam, and other criteria
  • Admit patients to healthcare facilities
  • Order, perform, and interpret lab, radiographic, and other diagnostic tests
  • Identify, develop, implement, and evaluate a plan of care
  • Perform therapeutic procedures that the NP is qualified to perform
  • Prescribe treatments
  • Prescribe and dispense medications when granted authority
  • Perform additional acts NPs are qualified to perform

But the language for the practice of NPs is much less clear in Arkansas, where an NP’s scope of practice is distinguished from an RN’s with a general descriptor that states they are to have “advanced knowledge and practice skills in the delivery of nursing services.”

Family Nurse Practitioner Education Requirements

FNPs like other APRNs, must hold a registered nurse (RN) license and be nationally certified and state licensed to practice as an NP.

To earn national certification as an FNP through either the American Nurses Credentialing Center or the American Academy of Nurse Practitioners and ultimately earn state licensure, nurses must complete, at a minimum, a Master of Science in Nursing (MSN) through a program accredited by the Commission on Collegiate Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC).

The program will include specific courses related to the MSN, such as evidence-based practice and organizational and systems leadership between 500 and 700 clinical hours related to the FNP role, and an APRN Core that includes the following courses:

  • Advanced physiology/pathophysiology, including general principles that apply across the lifespan
  • Health assessment, including the assessment of all human systems, and advanced assessment concepts, approaches, and techniques
  • Pharmacology, includes pharmacokinetics, pharmacotherapeutics, and pharmacodynamics

An FNP graduate program includes specialty courses and clinical rotations related to the FNP. These courses and experiences emphasize multicultural and underserved populations in primary care, women’s care, pediatrics, and more. FNP graduate programs prepare students to become providers of family-oriented primary care.

Specialty courses frequently found in an FNP program include:

  • Family Centered Advanced Practice Nursing: This course focuses on the influences of culture, society, behavior, and human development of families, as well as the relationship between family-centered healthcare and evidence-based practice, quality improvement, interprofessional collaborations, and safety.
  • Acute and Episodic Conditions: This course focuses on assessing, diagnosing, and managing patients with acute episodic illnesses and conditions across the lifespan. Genetic, epidemiological, pathophysiological, cultural, and family influences are considered. It also focuses on the FNP as a patient advocate who oversees the individualized treatment plan and patient care, safety, and privacy.
  • Chronic and Complex Conditions: This course focuses on the issues of co-morbidity, an aging population, and an increasing lifespan. Some of the areas studies include diabetes, cardiovascular disease, pulmonary disease, and rheumatologic conditions and the importance of emphasizing intervention and treatment options with a focus on quality of life, normal aging, and the optimization of health among those with chronic illnesses.

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