Q: I just saw a position paper on the BNE Website that states an APN specializing in psych-mental health may make a diagnosis from the DSM Manual. Does that mean that other APNs may not make a psychiatric diagnosis? If so, I am very concerned because I am a FNP who sees some mildly depressed patients and I have treated those patients in the past. Have I been providing a service that is outside my scope of practice?
A: No, you have not been providing a service that the BNE would consider to be outside the scope of practice for an FNP. Your scope of practice is largely based on the content that was included in your family nurse practitioner educational program, and most FNP programs include the diagnosis and treatment of mild depression.
The position paper to which you refer, “15.12 The Use of American Psychiatric Association Diagnoses by LVNs, RNs, and APNs,” is based on a position statement that was originally adopted in 1996 and revised in 2005. The purpose is to affirm that a CNS or NP who specializes in psychiatric-mental health (PMH) nursing may make a diagnosis from the Diagnostic Statistical Manual of Mental Disorders (DSM) as an independent nursing function. According to Jolene Zych, APN Consultant for the BNE, the position statement is not intended to indicate that other APNs are not authorized to diagnose from that manual, albeit in a much more limited scope than would be appropriate for a PMH CNS or NP.
Your question also touches on an issue that deserves further comment regarding the extent to which an APN educated in a primary care specialty may diagnose and treat psychiatric-mental health disorders. Not only has this issue generated a significant number of questions to the BNE, it has become a hotly debated issue among some local groups of NPs. Unfortunately, as in most scope of practice questions, the boundaries of appropriate practice are somewhat blurry and based on the educational background of the individual NP.
For instance, primary care NPs that graduate from the program at UT Arlington have a two credit hour course dedicated to PMH on an advanced nursing level. As a consequence, it may be appropriate for an NP who graduates from UT Arlington to diagnose and treat a slightly wider range of mental health conditions as part of their primary care practices than it would for most NPs. However, even FNPs who have taken several PMH courses must understand that unless they are certified in PMH and authorized to practice as a PMHNP or PMH-CNS by the BNE, they must carefully limit the types of patients they treat for PMH diagnosis.
When considering appropriate limits for an NP educated in a primary care specialty in treating patients with psychiatric conditions, sometimes it is easier to identify clients and functions that would clearly be out of your scope of practice.
It would NOT be appropriate to provide mental health counseling sessions or psychotherapy for individuals or families. While it may be quite appropriate for a primary care NP to offer guidance and preventive counseling on some mental health issues such as post partum depression, attention deficit hyperactivity disorder, appropriate discipline for children and healthy family functioning, it would not be appropriate to provide and bill for actual mental health counseling sessions. Psychotherapy or other forms of mental health talk therapy are clearly the purview of APNs who specialize in PMH or other appropriately trained and licensed psychologists or mental health counselors.
Likewise, it would NOT be appropriate for a primary care NP to treat patients with schizophrenia, major depression, unstable bipolar disorder, anti-social personality disorders, and a host of other psychological disorders that require the care of a specialist. While you may have those patients in your practice to provide their primary health care and you need to also ensure that these patients are receiving care for their mental health conditions by the appropriate specialist/s.
With severe shortages of mental health professionals in many areas of Texas, it often falls to primary health care providers to treat certain psychiatric conditions. However, it is essential for NPs to be aware of appropriate scope of practice boundaries in treating these conditions. |
