We’ve been profiling various nursing specialties so that you can get more information about what the job entails and what education you would need if you’d like to consider that specialty. Next up—Family Nurse Practitioner (FNP).
According to Miranda “Mandy” Wiggins, CRNP, an FNP with
Main Street Family Care in Alabama, FNPs are responsible for patients from
birth to geriatrics as well as all aspects of that care. They provide
comprehensive treatment and see patients for yearly wellness visits, write
prescriptions for them, order any necessary testing, and follow up to review
results of testing.
In addition, Wiggins says, “We are there for them for acute
illness and management of chronic medical issues.”
She admits that one of the biggest challenges in being an FNP is educating patients. Often, patients don’t understand that FNPs can provide many more services than an RN. They think that nurses and FNPs are the same position.
But there are so many more rewards to this job. “I chose
to be a family practitioner so that I could impact as many demographics as
possible in my practice. I enjoy providing care to patients of all ages and
presentations,” says Wiggins. “I enjoy the interaction with the patients and
the involvement of family members to ensure they are being given the best care
in and out of the office. They will remember that you took time to give them
resources and helped plan for their future needs.”
“The greatest reward is most definitely the continuity of
care we are able to provide from our listening and diagnostic skills to
providing follow-up care and establishing a trusting relationship with those
patients. It’s very rewarding to see them improve in their plan of care and to
be able to care for them over a period of years,” she says.
If you’re thinking of becoming an FNP, Wiggins says that the NP program usually takes two years to complete after earning a bachelor’s degree—if the student attends full-time. This timeframe includes a residency program and leadership/professional practice courses. Certification is also a must.
“If you love your patients and have a desire to serve, go for it!” says Wiggins.
A Certified Registered Nurse Anesthetist’s (CRNA) day begins with an inspection of the OR he or she is assigned to, with priority over the OR table and anesthesia equipment. Immediately before seeing the patient, a CRNA reviews the patient’s chart for any red flags, including information the patient may not willingly divulge. Examples of red flags include: a previous surgery, current medications (particularly cardiac medication and narcotics), and BMI. All of these factors can significantly impact how the patient will respond to anesthesia and surgery.
When meeting the patient, both a conversation and a physical exam ensue, as this is the final opportunity to determine what the CRNA can reasonably expect hemodynamically from the patient during the case. While inspecting the patient’s anatomy, a CRNA may ask how many stairs they can climb before getting winded, or how many pillows they use to sleep comfortably at night. All of this information combined will inform the American Society of Anesthesiology (ASA) score assigned the patient, which is a scale from one to five, one being a healthy patient and five being a moribund patient. This will be announced during the surgical time out.
In New York and Pennsylvania, CRNAs do not have APN status, which means that they work under the supervision of a physician and that one anesthesiology attending physician covers a handful of operating rooms, either overseeing a CRNA or medical resident in each. This anesthesiologist is expected to be present for induction, intubation, emergence, and extubation, as well as frequent check-ins throughout the case.
In all other states where CRNAs do have APN status, they perform collaborative care, which involves much less oversight. Nurse anesthetists practice under supervision of the surgeon with no physician anesthesiologist requirement in 49 states and completely independent of a physician in 17 states.
What every CRNA must carry over from days as a critical care nurse is nursing intuition, strong assessment skills, and a sense of resilience. It is not a position for shrinking violets; your voice as the patient’s advocate is more important than ever. A patient may be deemed unfit for general anesthesia based on assessment. The CRNA who cancels a surgery will find it is almost never received well by the patient, nor the surgical team or the nursing team who prepared for surgery. A significant portion of any CRNA’s day may be making decisions on the patient’s behalf that are unpopular.
On any given day, depending on what type of surgeries are being done in a given OR, a CRNA may see one patient or twelve during a twelve-hour shift. While doing a series of quick hysteroscopies on young women may mean your patients are healthier, the challenge is to keep pace and to do so without sacrificing thoroughness. Having every patient’s life essentially in your hands is nothing to take lightly, no matter how clean their health record may be. After each case, the CRNA has to make sure every patient is stable in recovery before leaving them with the PACU team. It’s then on to the next patient to do it all over again.
In order to become a Certified Registered Nurse Anesthetist, you must graduate with a minimum of a master’s degree from an accredited nurse anesthesia program and pass the national certification exam, which is administered by the National Board of Certification and Recertification for Nurse Anesthetists.
The term “midwife” literally means “with woman.” Although nurse-midwives are best known for their work during pregnancy and specifically labor and delivery, nurse midwives care for women’s health in a comprehensive way. Certified nurse midwives (CNM) are advanced practice nurses specializing in prenatal care, labor and delivery, postpartum care, gynecology, well women’s health care, and family planning. They work anywhere other advanced practitioners do: in the hospital, at the clinic, and at home.
In the past, many people thought of midwives as only assisting women in home births, water births, and labor without anesthesia. Although some women may choose to deliver their babies in this way, midwives actually oversee all types of births, including those that are more conventional in the hospital. Nurse midwives have the credentials and authority to empower patients, so the kind of care given is according to their preferences and in their best interest.
Despite common misunderstandings, nurse midwives are qualified
to care for women during various stages of life. Furthermore, as prescribers
and independent providers, they are able to manage all types of pregnancies,
whether straightforward or complicated. Like other advanced practice nurses,
many midwives have years of experiences as registered nurses in labor and
delivery and other areas of women’s health. Many contend that the unique
experience of working as a registered nurse before advancing is what sets nurse
practitioners, including midwives, apart from their physician counterparts.
Within midwifery, there are stratified scopes of practice and levels of education; this is both location and training-dependent. Just like other advanced practice nurses, midwives work with varying degrees of independence from physician oversight in an ever-changing climate of advanced practice patient care. The majority of midwives hold a master’s or doctorate nursing degree (CNM); there are also certified midwives (CM) who have passed their advanced practice boards while maintaining a bachelor-level degree of education. For those who don’t have a bachelor’s, master’s, or doctorate degree can qualify to be a certified professional midwife (CPM). They are either trained through apprenticeship and/or formal education, and their scope of practice is narrower than CNMs.
As standards of health care providers evolve, the accreditation process for nurse midwives has increasing standards. The good news is that nurse midwives are learning through rigorous training and experience to provide high-quality patient care independently. Nurse midwives are more than the overseers of alternative birthing methods. They are fully licensed and independent women’s health providers.
For more information on this career path, visit DailyNurse.com/nurse-midwife.
A 2018 study by the American Enterprise Institute (AEI) called “Nurse Practitioners: A Solution to America’s Primary Care Crisis,” by Peter Buerhaus, suggested that NPs can help with the problems of not having enough primary care physicians in particular areas of the United States.
David Hebert, JD, Chief Executive Officer of the American Association of Nurse Practitioners (AANP), recently explained how NPs can make a difference and what can stand in their way.
What follows is an edited version of the interview.
How many states restrict NPs scope-of-practice? What are the limits—what are they not allowed to do in these states that other states allow them to do? If they are allowed their total scope-of-practice, are they able to do everything that a primary care doctor can do?
Currently, 28 states don’t allow NPs to practice to the fullest extent of their training and licensure. Twelve of these—including California, Texas, and Florida—are “restricted practice” states, where the law restricts NPs ability to provide care without a formal contract with a physician. Sixteen other states, including Pennsylvania, Ohio, and Kentucky, are “reduced practice” states, where state regulations limit NPs’ ability to treat patients in certain care settings.
In 22 states, the District of Columbia, and Guam, NPs have full practice authority. This means NPs evaluate patients, diagnose, order and interpret diagnostic tests, as well as initiate and manage treatments under the exclusive licensure authority of the state board of nursing.
NPs and physicians both have the skill set to provide the full range of primary care services to patients. It’s not really about the provider—it’s about giving patients a choice of provider and ensuring them access to high-quality health care. NPs are a critical component of care teams. We work with all kinds of providers in every care setting to make sure patients get the best possible care. When it comes to scope-of-practice laws, we want NPs to be allowed to practice to the fullest extent of their training and licensure.
With the lack of primary care physicians, especially in rural and medically underserved areas, what can the NP bring to the community?
NPs ensure patients in rural communities have greater health care access, especially in primary care. The AEI report confirmed that while the NP workforce is growing significantly, the physician workforce is growing at a much slower rate. The study also concluded what we’ve seen in our own work: primary care NPs (PCNPs) are more likely to practice in rural areas, where the need for primary care is greatest.
It’s important to remember that primary care can prevent additional health complications for patients, making NPs a vital resource for rural communities. People living in states with laws that reduce or restrict NPs’ scope-of-practice have significantly less access to PCNPs. This finding indicates that such state regulations have played a role in impeding access to primary care. This alone should be cause for concern among policymakers seeking to improve public health.
When NPs have moved into areas and had the complete ability to practice, what have been some of the results?
In U.S. News & World Report’s 2018 Best State Rankings, nine of the top ten states for best health care allow patients full and direct access to NP care. According to Buerhaus, author of AEI’s report, people living in states that do not restrict NP scope-of-practice have significantly greater geographic access to primary care. More and more people are choosing NPs because the quality is high and accessible as well as because NPs take into account the needs of the whole patient, which resonates with today’s families.
What would you say to patients who might be afraid that they are getting lesser care in being treated by an NP as opposed to a doctor? How can NPs and other health care providers help patients to understand the benefits?
It’s important for patients to feel comfortable in their selection of a health care provider. Research shows that NPs achieve health outcomes for their patients equal to—and in some cases—greater than their physician counterparts. We encourage patients to consider an NP, take time to learn more about the care NPs provide at www.WeChooseNPs.org, and if it’s the right choice for them, to visit NPfinder.org, where they can find an NP in their area.
We’ve launched a nationwide campaign called We Choose NPs that showcase patients who choose NPs as their primary care providers. We believe it’s important for patients to have access to high-quality primary care and to have the information available to make the right health care choice for their family.
NPs are strengthening health care in a variety of important ways. Recently, Congress passed comprehensive opioid legislation that makes permanent the temporary authorization granted nurse practitioners (NPs) and PAs to provide lifesaving medication assisted treatments (MATs) for patients battling addiction. After conducting a billion patient visits last year alone, we’re very excited about the future and the opportunity to help patients nationwide.
According to Joyce Knestrick, PhD, C-FNP, APRN, FAANP, President of the American Association of Nurse Practitioners (AANP), Congress recently passed and President Trump signed “a comprehensive package of anti-opioid bills into law with a key provision permanently authorizing NPs to prescribe Medication-Assisted Treatments (MATs), further expanding patient access to these critical treatments.”
This passage is extremely important to those fighting opioid addictions as well as those health care workers who are treating them. “Recognizing the ongoing impact of the opioid crisis, Congress and the President moved quickly to get this critical legislation across the finish line. We applaud their actions, which acknowledge the vital role nurse practitioners play in treating patients with opioid use disorder with Medication Assisted Treatments (MATs),” says Knestrick.
What does this mean for the health care community? Knestrick answered questions to explain.
Why is this important—both for NPs and for opioid addicts?
First and foremost, for the millions of American families struggling with addiction today, passage of this legislation ensures patients continuity of care, knowing that their NPs can continue to provide their loved ones access to MAT treatment.
Second, knowing that NPs are now permanently authorized to prescribe MAT, we anticipate significant growth in the number of America’s NPs who will become waivered to prescribe MATs—which will help turn the tide of opioid addiction in communities nationwide.
How will this help more opioid addicts?
As primary care professionals, NPs really are on the front lines of combating the opioid epidemic. Tragically, eighty percent of patients addicted to opioids don’t receive the treatment they need, due in part to health care access challenges, stigma, cost, and other factors. Thanks to advances in Medication-Assisted Treatment—which combines medications that temper cravings with counseling and therapy—and this new law granting NPs permanent authority to prescribe MATs, the opportunities to reach and treat patients struggling with addiction are better than ever before.
In addition to helping addicts, will this make the process more cost-effective? If not, how else will it be beneficial to health care facilities and/or treatment centers?
We do know that treating people with addiction to opioids and other substances is costly—in part because of the need for in-patient treatment and more frequent hospitalizations. Yet, most people in need of treatment simply don’t receive it. As a nation, we are facing significant shortages of specialty treatment facilities for addiction, and this makes it all the more important to ensure that NPs and other primary care providers have the tools to meet the patient need for MATs
AANP has formed a collaborative with the American Society of Addiction Medicine and the American Association of Physician Assistants to provide the 24-hour waiver training for NPs and physician assistants. We invite NPs to visit AANP’s CE Center at https://www.aanp.org/education for more information.
Vanderbilt University School of Nursing recently received a $1.43 million award from the US Health Resources and Services Administration (HRSA) to develop and implement a Sexual Assault Nurse Examiner (SANE) education program for emergency nurse practitioner (ENP) students. The program is expected to increase the number of SANE-trained advanced practice registered nurses practicing in emergency departments and rural or underserved communities across the country.
Mavis Schorn, PhD, FACNM, the grant’s principal investigator, tells Nursing.Vanderbilt.edu, “Currently, there are just over 800 sites in the country that provide SANE services, yet nationally, one in six women and one in 33 men will experience an attempted or completed rape in their lifetime. Sexual assault nurse examiners have specialized education to conduct forensic examinations that have been shown to provide better physical and mental health care for assault survivors, deliver better evidence collection and support higher prosecution rates. Most important, SANEs treat patients holistically with compassionate and comprehensive care that takes into account the patient’s current acute care needs and the possible long-term effects of sexual assault.”
ENPs are positioned in emergency departments and are often the first to discover a patient who has been sexually assaulted. Their education and experience allows them to provide primary, episodic, and critical care of males and females of all ages.
Vanderbilt will offer SANE education to students in the Emergency Nurse Practitioner Post-Master’s Certificate program. Students in the program are current family nurse practitioners who want to become ENPs, and they will complete SANE training and their ENP education simultaneously with an option to select adult/adolescent and/or pediatric/adolescent SANE training.
The initiative is supported by Vanderbilt University Medical Center, Our Kids, Nashville’s Sexual Assault Center, and EmCare. To learn more about Vanderbilt Nursing’s $1.43 million HRSA grant to develop sexual assault nurse examiner education, visit here.