Original article – Role & Scope of Practice of a Family Nurse Practitioner on nursejournal.org
Family nurse practitioners (FNPs) are graduate-educated, nationally certified, and state-licensed advanced practice registered nurses (APRNs) who care for medically stable patients across age groups, including infants, adolescents, adults, and seniors. Nurses in a family nurse practitioner role typically earn certifications to work with specialized patient populations. These certifications are issued by the American Nurses Credentialing Center (AACN) or the American Association of Nurse Practitioners (AANP) and they indicate a practitioner’s expertise. An FNP nurse is a particular variety of nurse practitioner (NP), and they may be called FNPs, APRNs, or NPs.
What is an FNP?
Just like a primary care physician, FNPs provide lifelong, comprehensive care through disease management, health education, and preventative health services. They are qualified to perform the following tasks:
- Manage chronic conditions, like hypertension and diabetes
- Oversee the health and wellness of pregnant 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 age groups
FNPs often work with other specialists to co-manage their patients’ conditions and provide case management for long-term illnesses and injuries. Typical duties include diagnosing conditions, ordering and interpreting diagnostic tests, conducting examinations, providing counseling, and sometimes prescribing medications. FNPs can earn a variety of additional specialty certifications in areas like cardiology, women’s health, and neurology.
Because of their broad knowledge base and patient population experience, FNPs are found in diverse settings, including independent private practices with other NPs, physician’s offices, major hospitals, schools, state and local health departments, community clinics, and other ambulatory care facilities.
In some areas of the country, particularly in rural or urban settings where physician shortages are prevalent, FNP nurses are the sole healthcare providers, sometimes with oversight from a licensed physician. Because FNPs have been educated at the post-bachelor’s level in health diagnosis and assessment, physiology, and pharmacology, they are sometimes able to practice autonomously and serve in a primary care role. They provide much-needed services to underserved populations that would otherwise have limited access to healthcare.
NPs are not uniformly regulated. Instead, family nurse practitioner scope of practice is determined by the state licensing authority, and regulations vary between states. Still, the unique level of accountability for FNPS must be stressed: According to the AANP, FNPs are held accountable through peer review, clinical outcome evaluations, and professional development requirements. They are leaders and educators who advocate for patient needs and the advancement of health policies.
Scope of Practice is Determined by State Boards of Nursing: Independent Practice and Prescriptive Authority
Under the guidance of the National Council of State Boards of Nursing (NCSBN), dozens of influential nursing organizations, including certification agencies and professional advocacy groups, are working at the state and national levels to advocate for legislative reform allowing all NPs to practice independently, without physician oversight.
Twenty seven states currently require physician oversight or direct supervision for FNPs, which is becoming an issue as physician shortages loom. According to the Association of American Medical Colleges (AAMC), a 2018 report projects overall physician shortages of 42,600-121,300 practitioners by 2030. Of those, 14,800-49,300 will be in primary care positions.
Many state boards of nursing, like Alaska, Hawaii, and Washington, grant NPs the power to practice autonomously. This means that FNPs in those states can practice independently and prescribe medications without physician oversight. As of 2019, 23 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
While all state codes now recognize NPs as primary care providers, in many states they cannot write prescriptions. For example, NPs in California can prescribe medicine, but their prescriptions must be endorsed by physicians before they are eligible for insurance reimbursement. In Oklahoma, NPs can apply for independent prescriptive authority, but only with approval from a licensed physician. Alabama is so restrictive that NPs must practice at least 10 percent of the time alongside their collaborating physician.
Other states are much more progressive, giving NPs latitude to practice autonomously. For example, in Washington, NPs enjoy most of the same privileges physicians have, including admitting and discharging patients from hospitals and other healthcare facilities.
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 a registered nurse (RN). For example, Arizonaprovides a detailed list of NP powers:
- Examine patients and establish medical diagnoses by client history, physical exam, and other criteria
- Admit patients to and discharge them from healthcare facilities
- Order, perform, and interpret lab, radiographic, and other diagnostic tests
- Identify, develop, implement, and evaluate a plan of care
- Perform therapeutic procedures
- Prescribe treatments and medications
- Perform additional acts as licensure allows
In contrast, restrictions for NPs are much less clear in Arkansas, where an NP’s scope of practice is distinguished from an RN’s with only a vague requirement that they have “advanced knowledge and practice skills in the delivery of nursing services.” You can learn more about specific state nursing practice regulations at the AANP’s website.
Family Nurse Practitioner Education Requirements
Like other APRNs, FNPs must hold an RN license and be nationally certified and state licensed to practice as an NP.
To earn national certification as an FNP nurse through either the ANCC or the AANP, nurses must complete at least a master of science in nursing (MSN) through a program accredited by the Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), or the National League for Nursing Accrediting Commission (NLNAC). The program will include specific courses related to nursing, including evidence-based practice, organizational leadership, and 500-700 clinical hours related to the FNP role.
State licensure requirements vary, so be sure to check regulations for the state where you plan to practice.
Admission Requirements for an MSN Degree
To apply directly to an MSN program, nursing students must have the following:
- A bachelor’s degree in nursing (BSN) from an accredited college or university along with accompanying transcripts
- A valid RN license
- RN work experience within the last five years with a completed work verification worksheet
Pre-licensure BSN programs require prospective nursing students to submit a background check, but for most BSN programs an RN license will serve this purpose. Additionally, work experience is not always a prerequisite, though it never hurts. International students must also provide proof of English proficiency.
Aspiring nurses without a nursing degree can still pursue an MSN. The application process is similar to the requirements for those with a BSN, but applicants must also take prerequisite courses covering natural, behavioral, and social sciences. Specifically, non-nursing degree applicants need credits in human anatomy, microbiology, psychology, physiology, communication, and statistics.
Concentrations Offered for Family Nurse Practitioners
CARDIOLOGY
Cardiology-focused MSN graduates find work treating patients with heart disease, including arrhythmia, high blood pressure, and congestive heart failure. Through specific coursework and 200 additional clinical hours working under the supervision of an expert cardiovascular clinician, students graduate ready to apply cardiology best practices and implement the latest evidence-based knowledge as an FNP nurse.
NEONATOLOGY
A subspecialty of pediatrics, neonatology focuses on the care of newborns, especially infants or “neonates” who are born prematurely or with illnesses. Through focused coursework and clinical practice, prospective neonatal FNPs develop expertise in clinical management for acutely or chronically ill neonates.
EMERGENCY MEDICINE
FNP graduates trained in emergency medicine learn to evaluate, assess, diagnose, treat, and educate patients experiencing acute or life-threatening health issues. Operating under pressure requires quick thinking and a level head, and this specialty prepares FNPs to provide urgent, evidence-based care to patients experiencing medical crises. Emergency medicine FNPs might work in hospitals or family clinics.
ONCOLOGY
Another specialty nurses can add to a FNP nurse designation is oncology, which trains them to work with cancer patients and their families. Students study topics like cancer prevention, disease treatment, symptom management, palliative care, and epidemiology as it pertains to cancer types. This specialty typically requires three additional courses and more than 200 clinical hours.
WOMEN’S HEALTH
The women’s healthcare specialty focuses on health issues and conditions typically associated with women, including reproductive health, gynecological care, and prenatal and postpartum care. The specialization also covers disease prevention and health education specific to healthcare for women, and FNPs in this specialization can work in hospitals, ambulatory facilities, and family clinics.
Sample Courses for a Family Nurse Practitioner Program
- Advanced Pathophysiology: This FNP nurse course studies organ systems, their normal functions, and disordered physiology. With this understanding, nurses can better evaluate and assess symptoms, diagnose conditions, and recommend suitable therapy. Topics include physiology, pathologic mechanisms, and clinical assessment.
- Chronic Illness Concepts: In this course, students focus on chronic illness — in particular, common disease trajectories. The course delves into theories and research surrounding chronic illness as well as the impact of social, psychological, economic, and quality of life issues on patients, caregivers, families, and communities at large.
- Pediatric Health Promotion: Students in this course study theories of health promotion and maintenance for the care of children and adolescents. Covered topics include health screening, behavioral stresses, developmental stresses, and counseling strategies for parents and children to promote growth and reduce risk.
- Advanced Clinical Pharmacology: In this course, students explore pharmacokinetics, the movement of drugs within the body, and pharmacodynamics, the effects of drugs and their relative actions, to understand how medication helps manage disease in a clinical setting. Students learn about major classes of drugs, including therapeutic effects and potential adverse reactions. Course topics include diagnostic reasoning, pharmacological intervention, and the ethics of prescribing medication.
- Adult-Gerontology Primary Care: Nurses typically take two courses focused on adult populations. The first course covers theoretical strategies for assessing both acute and chronic health problems in adults, including common and rare ailments. Students then graduate to the clinical course, where they incorporate that knowledge in a clinical setting.
How Long Does It Take to Complete a Family Nurse Practitioner Program?
The time it takes to complete a family nurse practitioner program varies by level of education and nursing experience. Chosen subspecialties like cardiology, emergency care, or women’s health also factor into how long it takes to become a licensed FNP nurse. Course style also makes a difference: Full-time students can finish in about half the time it takes part-timers.
A CCNE- or ACEN-accredited MSN program typically requires 30-36 credits and takes 2-3 years to complete. This timeline applies to students who already hold a bachelor’s degree in nursing and an RN license. Full-time students enrolled in a BSN-to-MSN program can take 15-25 months to fulfill all requirements, while part-time students can take up to 40 months.
Note that RN-to-MSN programs, which accept students with an associate degree or diploma in nursing, typically take full-time students three years to complete and part-time students 4-5 years. RNs who hold an MSN and return to school for FNP certification can finish in about a year, depending on specialty and related clinical hour requirements.
Clinical Hours for Nurse Practitioner Students
FNP students should expect to spend 500-700 hours in the field, some of them through a preceptorship, where a practicing physician mentors them in a clinical setting. Clinical rotations allow future NP nurses to experience life as an FNP in a variety of healthcare settings, including cardiology, maternity, and palliative care wards. For most online programs, schools assist students in finding placements at local health facilities.
To fulfill the FNP definition and sit for the ANCC certification exam, FNP nurse candidates need at least 500 faculty-supervised clinical hours. Note that minimum required clinical hours may vary depending on specialty. In addition to 500 hours of direct care, students also gain practical experience through labs and simulations.