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At the same time the issue of psychologist prescribing has been the focus of intense concentration in American psychiatry, nurse practitioners have quietly gained prescribing privileges in at least 35 states.
Now, nurse psychotherapists and psychiatric clinical nurses are pushing to gain prescriptive authority. The issue is emerging as a major challenge to those concerned about scope of practice and its potential adverse impact on quality of patient care, and will share a forum with psychologist prescribing at APA’s State Legislative and Public Affairs Joint Institute in Fort Lauderdale, Fla., next month.
The specifics vary from state to state. For psychiatry, however, the underlying issue is the impact of expanded scope of practice on patients who may be denied insurance coverage for visits to a psychiatrist but will be reimbursed for visits to a nurse, or who may believe that they are receiving a comparable level of care from a nurse practitioner authorized to prescribe psychotropic drugs.
"We need to distinguish between nurse practitioners, who have greater training in diagnosis and treatment and are more likely to practice in close proximity to collaborating physicians, as opposed to master’s-level nurses with a specialty in mental health," observed Katherine Becker, J.D., deputy director for state affairs in APA’s Division of Government Relations.
Mental health nurses come under different titles, including nurse psychotherapist or psychiatric nurse clinical specialist, explained Becker. "It is [this] group that is really trying to expand their scope of practice by seeking prescribing authority where they don’t have it or by gaining independence from physician supervision where they already have circumscribed prescribing authority," she added.
Unlike psychologists, nurse practitioners have substantial medical education and may be required by state boards of nursing to augment that education with pharmacology course work. There is some ambiguity about who is a nurse practitioner for state regulatory purposes, adding to the confusion of both legislators and those who are fighting to restrict the prescriptive authority of nurse psychotherapists and psychiatric clinical nurses. In some states, nursing professionals, in addition to nurse practitioners, have lobbied successfully for inclusion under the category of nurse practitioner to gain prescribing privileges.
In New Jersey, for example, a nurse applying for certification as a nurse practitioner must complete a master’s program in nursing that includes a pharmacology course. If the applicant completed the pharmacology course more than five years prior to applying, he or she must successfully complete one of the following:
"1. A graduate level credit course in pharmacology from a school duly accredited by any national accrediting agency approved by the Board; or 2. Thirty contact hours in continuing professional education which are related to the applicant’s advanced category’s scope of practice; include pharmacokinetics and pharmacodynamic principles and their clinical application; include the use of pharmacological agents in the prevention of illness, restoration and maintenance of health; and are obtained within five years immediately prior to the date of application for prescriptive authority."
In Maryland, master’s-level nurse psychotherapists, who already are able to practice psychotherapy without supervision, have for the last two years lobbied aggressively for prescribing authority. They were successful in getting legislation through one chamber of the state legislature in 1996 and are expected to pursue similar legislation this year.
"Our position is that if they are going to prescribe, they should do so only in collaboration with a psychiatrist or a physician with substantial experience in treating mental illness," said Franklin Goldstein, J.D., lobbyist for the Maryland Psychiatric Society.
At this time, nurse practitioners, but not nurse psychotherapists, have the right to prescribe by written agreement with a collaborating physician. Nurse psychotherapists, however, must refer a patient they believe needs medication to a physician.
"The problem is that distinction [between the nurse practitioner and the other categories of nursing] has not been clarified," said Goldstein, "and where the nurse is the sole caregiver, that creates a problem."
He noted that the Maryland Psychiatric Society has been trying to work with nurse psychotherapists to "do what is in the best interests of mental health patients in Maryland." The concern is that some patients now treated independently by nurses may not be receiving needed medication. "We believe [psychotherapy] is best done in collaboration with a psychiatrist," remarked Goldstein.
In most of the 35 or more states where nurse practitioners have prescriptive authority, that authority is circumscribed either by limiting the kinds of drugs they may prescribe or by requiring some collaborative arrangement with a physician. In some states, however, nurses may prescribe independently with virtually the same authority accorded physicians. Even in those states where collaboration is required, the collaboration does not, in most cases, mandate direct supervision by a physician.
Apart from the issue of scope of practice, nurse prescribing authority has become a tool employed by psychologists lobbying for prescriptive authority. Psychologists have argued that if nurses can be permitted to prescribe a range of drugs after completing additional course work short of a medical degree, there is no reason that psychologists should not be permitted to do so after similar supplementary training.
APA’s Becker has seen heightened activity by district branches in opposition to nurse prescribing initiatives.
The expansion of nursing practice to include broad prescriptive authority, particularly among psychiatric nurses and nurse psychotherapists, represents "a significant threat to quality of patient care," Becker told Psychiatric News. "Prescribing bills enacted by nurses are often used as a legislative gateway for psychologists’ prescribing initiatives in the states," she added. APA’s Division of Government Relations is working to provide accurate information "that can be used to rebut the often overstated claims of certain nurses on nurse prescribing authority," Becker said.
In Michigan, all categories of nurses may prescribe only under "the specific delegated authority of a physician," said Kathleen Williams, executive director of the Michigan Psychiatric Society.
"This is not solely a turf issue, but also a health and safety issue for patients," said Williams. "We hope psychiatrists will work with physician colleagues for the protection of patients."
Last year the Michigan Psychiatric Society succeeded in amending a bill still under consideration so that "psychiatric nurse practitioners" would not be included in the proposal to grant independent prescriptive privileges to nurse practitioners, Williams explained. The outcome of the legislation remains uncertain, however, she said.
The argument against providing nurse practitioners with independent prescriptive authority was elegantly summarized in a recent newsletter from the Michigan Psychiatric Society.
"The extension of independent psychopharmacology practice to nurses has potential for doing harm to the public. Moreover, this potential may be realized as managed care pressures deny patients access to care from a psychiatrist or other physician since care by a nonphysician may, in the short term, be less expensive than physician-rendered medical care.
"Psychiatric nurses provide essential care to patients as part of the treatment team approach that has become the standard of practice in psychiatric care. In a number of Michigan hospitals, psychiatric clinical nurse specialists see patients in medication clinics, providing monitoring and follow-up care that includes writing prescription refills. Patients have the assurance that a psychiatrist makes the initial diagnosis and remains involved and responsible for their care. Patients are properly protected when the contribution of the physician to collaborative care is preserved.
"Psychiatrists stand side by side with psychiatric nurses in advocating for the full range of care that patients with mental illness need. Psychiatrists object to managed care pressures that marginalize the role of nurses. At the same time, the Michigan Psychiatric Society must object to opening the door that may remove the psychiatrist from the treatment team."