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The Journal for Nurse Practitioners 15 (2019) 479e482
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The Journal for Nurse Practitioners
journal homepage: www.npjournal.org
Family Nurse Practitioner Scope of Practice Issues When Treating Patients With Mental Health Issues
Melanie L. Balestra, JD, NP
Keywords: best practices civil and disciplinary actions family nurse practitioners licensing issues primary care mental health scope of practice
https://doi.org/10.1016/j.nurpra.2018.11.007 1555-4155/© 2019 Elsevier Inc. All rights reserved.
a b s t r a c t
In primary care settings, family nurse practitioners (FNPs) are often the first to see patients with mental illnesses. FNPs can diagnose and treat patients with uncomplicated mental illness, such as depression and anxiety, within their scope of practice (SOP). However, FNPs should be aware of areas that fall outside of their SOP, such as diagnosing and treating patients with complicated or severe mental illnesses or exceeding prescribing authority for psychiatric medications. Any breach of their SOP could lead to civil liability and disciplinary actions. FNPs should adopt best practices to ensure patient safety and protect their licenses.
© 2019 Elsevier Inc. All rights reserved.
Among mental illnesses, major depression is common, with
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Scope of practice (SOP) is a cornerstone for professional regu- lation used by nurse practitioner (NP) licensing boards across the country, usually a state’s Board of Nursing (BON). This concept defines the procedures, actions, and processes that NPs can perform as part of their professional licensure.1 Regulations are handled by each state and can vary from state to state.2
By definition, the SOP for family NPs (FNPs) is broad, with FNPs caring for a wide spectrum of patients (from pediatrics to geriatrics) and domains (private practices to hospital clinics and other outpatient settings, both urban and rural).2 In some rural or remote settings, FNPs may be the only health care provider available to patients.2
The SOP for FNPs could include providing mental health care services, and FNPs in primary care settings often are the first to see patients with common mental illnesses, such as depression and anxiety.3 In fact, FNPs are increasingly providing mental health care as demand from patients has increased. According to the National Institute of Mental Health, nearly 1 in 5 adults in the United States suffers from a mental illness (44.7 million in 2016).4 Among ado- lescents, an estimated 49.5% of young people aged 13 to 18 have had a mental disorder.4
approximately 16.2 million adults (6.7% of all US adults) having had at least 1 major depressive episode.5 Anxiety disorders also greatly affect US adults, with more than 31% having had an anxiety disorder sometime in their lives.6 Furthermore, this increase in patient demand has been exacerbated in recent years by a growing shortage of mental health care practitioners, including psychiatrists, whose numbers declined by 10% from 2003 to 2013.7
Although a legal or regulatory concept, the importance of SOP cannot be overstated. FNPs need to be familiar with their state’s SOP to ensure patient safety as well as to protect their profes- sional license, because acting outside of their recognized SOP in any patient care setting could expose them to civil liability and disciplinary actions brought by their BON, with the potential of having their professional licenses revoked.8 This is especially true when treating patients with mental illness or working with behavioral health issues, where an FNP may be trained and have the skills to diagnosis and initially treat mental illness but may be restricted by his or her SOP on the breadth and depth of care permitted.3
With that in mind, this article will outline several important SOP issues for FNPs working with patients with mental health issues and provide recommendations to help them ensure best practices and patient safety. The recommendations also will help them avoid blurring the boundaries delineated by their SOPs and protect their professional licenses.
FNP SOP Issues With Behavioral Health Care
Patients with mental illnesses, such as depression, anxiety, and attention-deficit/hyperactivity disorder, are often initially treated
M.L. Balestra / The Journal for Nurse Practitioners 15 (2019) 479e482480
by primary care providers such as FNPs.3 FNPs are well positioned to provide mental health care, going beyond mental health screening to initial intervention, which dovetails with the FNP philosophy of patient-centered care.9 However, FNP education covers only some aspects of mental health care and does not suf- ficiently prepare FNPs to treat patients with complex mental ill- nesses compared with psychiatric mental health NPs or other behavioral health specialists. FNPs should be aware of potential scenarios where the care they provide could breach their SOP. Below are some key examples of possible violations:
� Failure to monitor patient outcomes and refer patients to a psychiatric mental health NP, psychologist, or psychiatrist if symptoms have not improved, the patient is getting worse (acute decompensation) or is noncompliant, or the FNP disre- gards family members who have raised concerns about a patient.3
� Failure to refer patients with common mental illness, such as depression, when specifically required by a state’s SOP.3
� Failure to refer patients with complicated or severe (complex) mental illnesses, such as personality disorders, or if a specialist is needed based on the level of care or emergent conditions that prompt a referral/psychiatric consultation.3
� Exceeding prescribing authority for psychopharmacotherapy (in states where FNPs are authorized to prescribe/furnish such medications) or psychotherapy.3
� Failure to focus only on direct medical problems, such as blood pressure or diabetes, when treating patients with substance misuse diagnoses.
Any of these scenarios could lead to an allegation of a breach in SOP and a complaint to a state BON, which in turn would trigger an investigation and potential disciplinary action. A BON investigation has serious implications for any FNP, who would require legal assistance (and the associated costs of hiring an attorney) and could face the possibility of losing his or her professional license.10
A look at closed/paid claims in connection with legal assistance provided to protect NPs licenses provides FNPs with valuable in- formation about high-risk areas, including breaches in SOP. Ac- cording to a 2017 closed claims data analysis compiled by Nurses Service Organization (available on its website), SOP claims have increased significantly, with total claims more than doubling from 9% in 2012 to 22.1% in 2017, with an average payment in 2017 of $6,687.10 Within SOP allegations, allegations of “practice violates SOP and standards of care” were the most frequent (60.3%), with defense costs averaging $7,030.10
Considerations When Integrating Mental Health Care Into Practice
FNPs should consider the following recommendations to help them determine whether they are practicing within their SOP when treating patients with mental illness and to protect themselves from civil liability and BON disciplinary/license issues. FNPs should: