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.
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:
- District of Columbia
- New Hampshire
- New Mexico
- North Dakota
- Rhode Island
- South Dakota
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
- New Mexico
- District of Columbia
- New Hampshire
- Rhode Island
- 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.
Is It In Your Scope of Practice?
January 13th, 2012
By Jennifer Olin, BSN, RN
This week I have been talking about nurse practitioners broadening the scope of their practices in different states: how that would be beneficial, the organizations working for and against, and what some states allow and others don't. But it dawns on me the term "scope of practice" needs some definition.
As a nurse for a number of years, I think I know my own scope of practice. As a nursing student I heard the phrase a lot, read definitions, but they didn't mean much since I didn't really have any practices to fit into a scope—yet. So let's take a look at what the nursing scope of practice is and how it is determined.
To understand your nursing scope of practice you must first know what defines nursing. The American Nurses Association (ANA) provides a contemporary definition:
"Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations."
Ok, that sounds like a fancy variation on, "I want to help people." As nurses we commit to protecting the health of ourselves and others through education, hands-on care, and collaboration with other health care professionals. Those others we talk about can be found in hospitals, schools, neighborhoods, free clinics, doctor's offices and next door. So again, what determines if we are within our "scope of practice" to work with these other people?
We go back to the ANA and Nursing: Scope and Standards of Practice.
"The scope of practice statement describes the "who," "what," "where," "when," "why," and "how" of nursing practice. Each of these questions must be answered to provide a complete picture of the dynamic and complex practice of nursing and its evolving boundaries and membership. The profession of nursing has one scope of practice that encompasses the full range of nursing practice pertinent to general and specialty practice. The depth and breadth in which individual registered nurse engage in the total scope of nursing practice are dependent on their education, experience, role, and the population served. "
Now we have this textbook definition. It tells us we must answer certain questions to know if something falls in our "scope" and it tells us there are lots of variables. Let's break it down because even though we all went or are going to nursing school, because we all have or will pass our licensing exams, doesn’t mean we belong everywhere. For example, I am an OR nurse. I know a lot about anatomy, technology, machinery and instruments, positioning, pressure points and personality quirks of my surgeons. I am not an ICU nurse. I know how to take a blood pressure, use my stethoscope, and I actually still remember the differences between wheezing and rales. I no longer know how to set up a pump, am unfamiliar with the many kinds of cardiac drugs used today, and haven't managed a ventilator since nursing school clinicals; those skills are not in my scope of practice.
Here are some guidelines determining your own "scope of practice:"
- Did I learn this skill or task in my basic nursing program? – Every nurse, everywhere should know how to take a manual blood pressure. It is a basic skill taught in nursing school.
If you determine that the activity was not part of your basic nursing program, try these questions.
- Did I learn this skill/task as part of a comprehensive training program which included clinical experience? – In my OR residency program I learned about electricity and its uses in surgery, how and where to properly place grounding pad to prevent burns and other electrical accidents. I learned how to pass instruments, including knives, safely to the waiting hands of the surgeon and how to assist the anesthesia provider with intubating the sleeping patient. All skills particular to the operating room environment.
- Has this task become so commonplace in nursing literature and in nursing practice (wound debridement and dressing, for example) that it can reasonably and prudently be assumed within scope? – At one time only doctors attended to patient's wounds, but wounds of all kinds — burns, diabetic, surgical — are so commonplace today that pretty much all nurses know or have been shown how to do it.
- Is the skill/task in your hospital's/clinic's/agencies' policy and procedure manual? – If it is in the book, your employer believes it is a skill/task that is part of the job you were hired to do—your "scope of practice."
- Does this skill/task pass the "reasonable and prudent" standard of nursing? – A large part of nursing is using common sense. Being reasonable and prudent is simply showing care and thought for the future—pretty much the basic tenets of nursing. If what you are about to do fits those definitions it is in your "scope of practice."
If you can answer yes to all these questions, the skill or task is within your scope of practice.
Scopes of practice are the same for every nurse at a basic level and very different by specialty (OR, ICU, ER, Telemetry, Pediatrics, etc.); education (LPN, ADN, BSN, FNP, CRNA, DNP, and all those other initials), where you practice and who you serve. If you have a question about something you are asked to do; if you are uncomfortable with something you see, maybe it's not in your scope of practice. It is always better to hesitate, ask yourself these questions and check with someone else before you commit your patient and yourself to a course of action you shouldn't be on. Stepping out of your scope of practice can be a legal issue and endanger that license you worked so hard for.