January 16, 2008
PSYCHIATRIC NURSE PRACTITIONERS
By: John Kasprak, Senior Attorney
You asked for information on other states' recognition of psychiatric nurse practitioners.
Based on a survey of the National Council of State Boards of Nursing, about 23 states recognize in some manner a “psychiatric - mental health nurse practitioner.” Generally, such nurses are registered nurses (RNs) who have additional education (master's level or higher), training, and certification in a clinical specialty area. In many of these states, the title is a “clinical nurse specialist” (CNS).
We examined six neighboring states that recognize a psychiatric nurse practitioner, clinical nurse specialist – psychiatric mental health, or some variation. These are Maine, Maryland, New Jersey, New York, Pennsylvania, and Vermont. Maine recognizes a “certified psychiatric clinical nurse specialist” who can independently assess, diagnose, and therapeutically intervene in complex mental health problems using psychotherapy and other interventions. Maryland recognizes an “advanced practice registered nurse/psychiatric mental health” (APRN/PMH) who can perform independently, autonomously, and in a variety of settings. New Jersey recognizes 17 categories of clinical nurse specialists including a “psychiatric/mental health” clinical nurse specialist.
In New York, nurse practitioners are certified to practice in a specific specialty area, one of which is psychiatry. Vermont uses the APRN term to describe all categories of RNs in advanced practice nursing. These categories include a clinical nurse specialist in psychiatric and mental health nursing.
Finally, Pennsylvania passed legislation in its 2007 session clearly defining, for the first time, the specific education and training required for certification as a clinical nurse specialist.
Maine recognizes a “certified clinical nurse specialist” (CNS). A CNS is an RN who has (1) received post graduate education in a master's degree program accredited by the National League for Nursing (NLN) or American Association of Colleges of Nursing (AACN) in a specialty area in nursing and (2) been certified as a clinical nurse specialist by the American Nurses Credentialing Center (ANCC) or been certified in the clinical specialty by a national certifying organization acceptable to the Maine Board of Nursing. A CNS can include a certified psychiatric nurse clinical specialist (Maine Board of Nursing Regulations Relating to APRNs, Sec. 1 Definitions).
Scope of Practice
A CNS applies research-based knowledge, skills, and experience to intervene in human responses to complex health and illness problems. The CNS:
1. provides case management skills to coordinate comprehensive health services and ensure continuity of care;
2. evaluates client progress in meeting expected outcomes;
3. consults with other health care providers to influence care of clients, effect change in systems, and enhance the ability of others to provide health care; and
4. performs additional functions specific to the specialty areas; (for example, the certified psychiatric CNS may independently assess, diagnose, and therapeutically intervene in complex mental health problems using psychotherapy and other interventions) (Regs., Sec.1 Scopes of Practice).
The board reserves the right to make exceptions for approval of scope of practice for those CNSs in practice before January 1, 1996, based on consideration of national certification acceptable to the board, educational and clinical preparation, and practice for which competency has been maintained.
Requirements for Approval to Practice
In order to practice as a CNS, an applicant must:
1. submit evidence of completion of a master's degree program in a clinical specialty area accredited by the NLN or the AACN;
2. be certified in a clinical specialty area by a national certifying body acceptable to the board; and
3. pay the fee established by the board for initial approval.
Maryland defines an “advanced practice registered nurse/psychiatric mental health” (APRN/PMH) as an RN certified by the Maryland Board of Nursing to engage autonomously and independently in activities authorized by law. It also defines a “nurse psychotherapist” as an RN who uses psychotherapy in a formally structured, contractual relationship between the nurse therapist and a client (Maryland Board of Nursing APRN/PMH Regs. Sec. .02).
An applicant for certification as an APRN/PMH in independent practice must:
1. be an RN currently licensed in Maryland;
2. have a master's or higher degree;
3. hold current certification as a specialist in psychiatric or mental health nursing issued by the American Nurses Association (ANA) or other bodies approved by the Board;
4. complete the application for certification as a nurse psychotherapist; and
5. pay all Board-established fees (Sec. .03).
Scope of Practice
An APRN/PMH may perform independently, autonomously, and in a variety of settings, the following functions:
1. establish a mental health diagnosis;
2. evaluate and manage psychobiological intervention;
3. provide individual, group, and family therapy;
4. provide any therapy which purpose is to: (a) alleviate emotional disturbance, (b) reverse or change maladaptive behavior, and (c) facilitate personality growth and development;
5. consult with health care providers and others to: (a) influence clients' plans of care, (b) improve others' abilities to provide behavioral, psychiatric, and mental health care, and (c) effect systems change;
6. provide behavioral rehabilitation care; and
7. utilize advance practice skills to independently provide (a) case management, including psychiatric rehabilitation and home care and (b) health teaching, health promotion and prevention, and aid to the client in developing healthy living choices (Sec. .05).
Standards of Practice
The Maryland regulations establish the following standards of practice for APRN/PMHs.
1. Advanced practice skills must be used in the collection of relevant data to comprehensively assess the client's mental health.
2. Assessment data must be analyzed in determining diagnosis.
3. A plan of care must be developed and implemented that outlines treatment to attain expected outcomes.
4. Individual, group, and family psychotherapy, child psychotherapy, behavioral care, case management, and other therapeutic treatments must be used to assist clients in fostering mental health, preventing mental illness and disability, and improving or regaining previous health status and functional abilities.
5. Advanced knowledge of psychobiological interventions must be utilized and clinical skills applied to maximize the client's health and prevent further disability.
6. The use of psychobiological interventions does not authorize the prescription of medications.
7. The client's progress in meeting the expected outcome must be evaluated.
8. Strategies and interventions must be used to promote and maintain health and prevent mental illness.
9. Decisions and actions on behalf of clients must be determined in an ethical manner (Sec. .06).
Practice before Maryland Certification
An RN who meets the qualifications to sit for a national certifying examination acceptable to the Board or who has taken that exam and is awaiting the results, can practice in the state as an APRN/PMH if the:
1. practice is under the supervision of a Maryland-certified APRN/PMH who is readily available to the APRN/PMH graduate;
2. supervising APRN/PMH agrees in writing on a Board form to provide the supervision; and
3. APRN/PMH graduate completes the application for Maryland certification as a nurse psychotherapist and pays the application fee (Sec. .04).
Under New Jersey law, anyone wishing to practice or represent as a nurse practitioner/clinical nurse specialist, must be certified by the New Jersey Board of Nursing. (New Jersey Annotated Code, Sec. 13:37-7.1). New Jersey recognizes 17 categories of nurse practitioners or clinical nurse specialists that may be certified. One of these is “Psychiatric/Mental Health” (Sec. 13:37-7.11). Each certification applicant must submit the following to the board: (1) proof of current New Jersey RN licensure in good standing; (2) a completed application form and application fee; (3) proof that he or she has successfully completed certain educational requirements (see below); and (4) proof that he or she has successfully completed the examination requirements (Sec. 13:37-7.2).
After initial certification is granted, renewals are on a biennial basis.
Each certification applicant must successfully complete and graduate form a master's level program designed to educate and prepare the nurse practitioner/clinical nurse specialists at a school accredited by any board-approved national accrediting agency. The applicant must also successfully complete a graduate level course in pharmacology from an accredited school; this course can be integrated into the master's program. The law specifies somewhat different requirements for an applicant who completed the pharmacology requirements more than five years prior to filing an application (Sec. 13:37-7.2).
A certification applicant must successfully pass the highest level practice examination in the area of specialization approved by the board. An applicant meeting the educational requirements specified above must apply to take the first available examination for which he or she is eligible. The applicant may engage in advanced practice nursing pending the results of the exam, provided the applicant clearly delineates the word “applicant” each time he or she assumes the title or designation of a “nurse practitioner/clinical nurse specialist” or any of its abbreviations (Sec. 13:37-7.3).
Nurse practitioner/clinical nurse specialists must order and prescribe medications in conformance with the law and under protocols jointly developed with a collaborating physician. They must do so only at locations where these protocols are reviewed, updated, and signed at least annually by the nurse practitioner/clinical nurse specialist and the collaborating physician (Sec. 13:37-7.6).
An individual must be certified to use the title “nurse practitioner” in New York. Certification requires (1) a currently registered New York license as an RN and (2) meeting certain education requirements (discussed below). In New York, a nurse practitioner is certified to practice in one or more specific specialty areas. Each specialty requires a separate application and fee and a demonstration that educational requirements specific to that specialty have been met. Currently recognized nurse practitioner specialty areas are psychiatry, acute care, adult health, college health, community health, family health, gerontology, holistic nursing, neonatology, obstetrics/gynecology, oncology, pediatrics, palliative care, perinatology, school health, and women's health (Title 8, Article 139 of the New York Education Law; Part 64 of the Regulations of the Commissioner of Education).
An applicant for certification as a nurse practitioner must satisfy one of the following:
1. completion of a nurse practitioner educational program registered by the state Education Department as qualifying for certification, or a program determined by the department to be equivalent to a registered program, which is designed and conducted to prepare graduates to practice as nurse practitioners;
2. certification as a nurse practitioner by one of the following national certifying organizations: American Academy of Nurse Practitioners, Pediatric Nursing Certification Board, American Nurses Credentialing Center, National Certification Corporation, Oncology Nursing Certification Corporation; or
3. satisfaction of alternative certification requirements for nurse practitioner program graduates before April 1, 1989.
All nurse practitioner certification applicants must satisfy a pharmacotherapeutic requirement. The applicant must document one of the following:
1. completion of at least three semester hours in pharmacotherpeutics that includes instruction in drug management of clients in the nurse practitioner specialty area and in New York and federal law concerning prescriptions and record keeping;
2. completion of an educational program or course combination which is the substantial equivalent to that listed above;
3. satisfactory completion of an examination in pharmacotherapeutics acceptable to the department; or
4. satisfactory completion of a nationally recognized exam acceptable for New York licensure as a physician assistant or for certification as a nurse midwife.
An applicant satisfying all requirements for nurse practitioner certification is authorized to issue prescriptions.
Practice Agreements and Protocols
State regulations require that practice agreements and practice protocols be maintained in the practice setting of the nurse practitioner and collaborating physician and made available to the Education Department for inspection (Education Regs., Sec. 64.5). These agreements must include provisions for referral and consultation, coverage for emergency absences of either the nurse practitioner or physician, resolution of disagreements between them concerning diagnosis and treatment, and the review of patient records at least every three months by the physician. Protocols must identify the practice area performed by the nurse practitioner in collaboration with the physician and must reflect accepted standards of nursing and medical practice. The protocols must have provisions addressing case management, including diagnosis, treatment, and appropriate recordkeeping by the nurse practitioner.
Pennsylvania Public Act 49 of 2007 amends the state's professional nursing law to provide official recognition of the clinical nurse specialist (CNS). It clearly defines, for the first time in Pennsylvania, the specific education and training needed for certification as a CNS. Also, it requires them to carry liability insurance for the services they provide.
Previously, the licensing and educational requirements for a CNS were not defined in state statute or regulation. A state insurance law passed in 1986 listed CNSs as a category of nurse to be reimbursed for nursing services.
The new law defines a CNS as “a registered nurse licensed in this Commonwealth who is certified by the State Board of Nursing as a clinical nurse specialist.” The “practice of clinical nurse specialist” is “the provision of direct and indirect nursing at the advanced level.”
To be eligible for certification, an individual must:
1. be a licensed RN,
2. have completed masters or post-masters work in an accredited nursing or CNS program,
3. be nationally certified as a CNS in a designated specialty or in an area pertinent to the designated specialty or meet equivalency requirements, and
4. meet all other board requirements.
An applicant for CNS certification must apply to the nursing board and pay an application fee. Biennial renewal requires completion of 30 hours of board-approved continuing education credits.
The law also specifies that a CNS may not engage in the practice of medicine (prescribing, distributing, ordering medications) or in surgery.
The state nursing board is developing regulations for the certification of clinical nurse specialists in Pennsylvania.
Vermont uses the term “advanced practice registered nurse” to describe all the categories of RNs in advanced practice nursing. These categories include adult nurse practitioner, certified nurse midwife, certified registered nurse anesthetist, clinical specialist in psychiatric and mental health nursing, and clinical specialists who meet Vermont Board of Nursing-established criteria (Vermont Board of Nursing Regs., Chapter 4- Nursing; subchapter 8-Advanced Practice Nursing).
An RN holding a current Vermont license can practice as an APRN if he or she (1) has successfully completed a formal education program, approved by the nursing board or by a state or national accrediting agency, which prepares nurses to function in advanced practice nursing; and (2) is certified by a national certifying organization currently recognized by the state nursing board.
Scope of Practice
Under Vermont Board of Nursing regulations, an APRN practices professional nursing as an RN and accepts the responsibility, accountability, and obligation to practice according to current standards and functions as defined by the scope of practice statements for each specialty area and as developed by national professional nursing organizations.
The following “core standards” apply to all categories of APRNs.
1. The APRN performs medical acts independently within a collaborative practice with a licensed physician under practice guidelines that are mutually agreed upon by the APRN and collaborating physician and are jointly acceptable to the medical and nursing professions.
2. Practice guidelines must include (a) a description of clinical practice, including sites, focus of care, and general category of clients; (b) an indexed copy of standards for clinical practice including method of data collection, assessment, plan of care, and criteria for collaboration, consultation and referral; (c) the name of at least one unencumbered Vermont-licensed physician who practices in the same specialty area who will be routinely used for collaboration, consultation, and referral; and (d) methods of quality assurance.
The board regulations specify “practice guidelines for clinical specialists in psychiatric and mental health nursing without prescriptive authority,” which are the same as those listed above, except for the “unencumbered physician” provision.