Family nurse practitioner's scope of practice in treating mental illness in primary care in indiana

[Sam. W]

Hi there,

I only know Indiana is a reduced practice state, and the FNP in IN can treat GAD, depression. Are there any specific mental diseases that the FNP cannot diagnose and/or treat (any specific therapies that we need PA or MD's signature?) I think we cannot diagnose ADD, ADHD, Bipolar.

 

Thank you very much!

[Tegridy]

On 12/16/2022 at 11:02 AM, AM MSN said:

FYI from my state board:

”APRN scope is not determined by the setting in which the APRN practices.  The focus is on what it is the APRN is doing – what care are they providing and what care are they managing, and, for what population including level of acuity.  In short, an APRN-CNP may engage in mental health care consistent with the competencies validated by the national certification they obtained and maintain.  The national certifying examination is the determining factor as to the APRN’s role and the population focus for whom APRNs are formally educated to provide care/medical management. APRN licensure by the Board is based on the applicant having passed a national certification examination by an approved national certifying body, in a particular role  (certified nurse practitioner/CNP; certified nurse specialist/CNS; certified nurse midwife/CNM; or certified registered nurse anesthetist/CRNA) and in one of several different population foci (Family,  Adult-Gerontology Acute Care, Adult-Gerontology Primary Care, Pediatric Acute Care, Pediatric Primary Care, Women’s Health, Psychiatric/Mental Health, etc.).  An APRN may manage the care of those patients and conditions for which their formal education has prepared them, as evidenced by their national certification.  It can be helpful to look at the test plan for the APRN’s national certification as the APRN’s practice should align with the competencies validated by the national certification.”

They go on to state, “Managing more complex or severe mental health issues such as psychosis would require PMH certification, for example. Again, the APRN would look to the national certification they obtained and maintain, as certification validates their training, education and competencies regarding the types of conditions they can manage.”

That would be the last document I uploaded here. So to answer the OP’s question, it doesn’t matter the practice setting or what someone’s “opinion” is that FNPs should be treating, it’s what you’re trained and ultimately certified to do - and anything outside of stable anxiety, depression, and some states ADHD is outside of scope for anyone other than a psychiatric nurse practitioner. 

The stable part is  not mentioned in these documents. Nontheless if soem one is unstable I think anyone with half a brain knows they should be referred to inpatient level care. 
 

much of the testimonies via PMHNP mentioned in previous posts versus FNP is likely not related to FNP temporary providing treatment to patients before they can be seen by psych. It’s like due to companies like cerebral hiring FNP to be primaries for those with mental illless of which I would agree should be managed by those with primary training in the psychiatry sciences. 
 

I do agree FNP should not treat advanced psychiatric illness as the primary, but if someone does not meet criteria for inpatient psychiatric care and if there is a lapse between your encounter and evaluation by a specialist in psychiatry, you are not providing competent care by forgoing ALL treatment until they are seen. This is not a skin biopsy which can always wait. Learn your profession and limits and start appropriate pharmacotherapy while awaiting consultation. It is weak medicine to do anything otherwise. 
 

this is not an opinion, and is common sense, hence why they provide rather vague wording in the NP “scope” documents. 
 

I would beg to differ that even the education given to most PMHNP is adequate to care for most high risk psych patients. 

[Guest603994]

11 hours ago, Tegridy said:

The stable part is  not mentioned in these documents. Nontheless if soem one is unstable I think anyone with half a brain knows they should be referred to inpatient level care. 
 

much of the testimonies via PMHNP mentioned in previous posts versus FNP is likely not related to FNP temporary providing treatment to patients before they can be seen by psych. It’s like due to companies like cerebral hiring FNP to be primaries for those with mental illless of which I would agree should be managed by those with primary training in the psychiatry sciences. 
 

I do agree FNP should not treat advanced psychiatric illness as the primary, but if someone does not meet criteria for inpatient psychiatric care and if there is a lapse between your encounter and evaluation by a specialist in psychiatry, you are not providing competent care by forgoing ALL treatment until they are seen. This is not a skin biopsy which can always wait. Learn your profession and limits and start appropriate pharmacotherapy while awaiting consultation. It is weak medicine to do anything otherwise. 
 

this is not an opinion, and is common sense, hence why they provide rather vague wording in the NP “scope” documents. 
 

I would beg to differ that even the education given to most PMHNP is adequate to care for most high risk psych patients. 

First off, “stable” means you’re not changing anything. You continue to prescribe the medication they’re already being prescribed, likely by psych. If they’re stable and saying depressed, you refer and likely they’ll get an appointment before any medication you think to try will kick in. But if you want to try something relatively low on the side effect scale and you’re confident in your abilities, how do you know it’s not bipolar II you’re treating? How do you know you didn’t send them into full blown mania? 

So from what you’re trying to argue, FNPs have been tested and educated while in school for bipolar d/o on screening, diagnosing, and medication management? It’s not emergent for an FNP to treat schizophrenia or bipolar or even anxiety and depression - because if it were, it means they’re unstable and you send them to the ER. If they’ve had symptoms for 5 years with no treatment, why does the FNP insist on treating rather than having them wait for a referral? If it’s anxiety or depression, grab an SSRI and a referral, but why are we even talking about anything beyond this? 

Same point you just made with derm - it’s not an emergency, so stay in your lane. Which was exactly my point - it’s not necessary in the moment, and even if I’m trained and confident to do it, it’s not my scope, so WHY in the world would I do it? 

Im not sure why you guys are having such a hard time with this and now you’re insulting the PMHNP profession which is childish. I could give very specific information on the awful things I’ve seen FNPs do in the 20 years of my career, but insult an entire profession won’t make my point more credible. 

Despite having no formal training in the area, even though it says you must be trained in school and then tested on the subject in your certifying boards in the documents I provided, you INSIST it’s still your scope because it doesn’t share minimum here. That’s a scary thing and it makes sense why when I get a patient from PC I’m constantly changing the mess they made. You’re doing far more harm, including many MDs and DOs who claim to have experience in the area. 

This was a link that didn’t share earlier from the BON - notice “Has the nurse completed the necessary education to safely perform the activity, intervention or role?” Followed by, “Is there documented evidence of the nurse’s current competence (knowledge, skills, abilities, and NO judgments) to safely perform the activity, intervention or role?” “Would a reasonable and prudent nurse perform the activity, intervention or role in this setting?” Because these are the questions you get asked in a court of law and if it’s no to any of the 3, you’re guilty for practicing outside of your scope. If you cannot furnish a PMHNP certificate and you get called into court, it’s your license and at the very minimum your insurance rates just went up. Again, this is bad advice and it’s your license, people.

https://boards.bsd.dli.mt.gov/_docs/nur/sp_model.pdf

[Tegridy]

36 minutes ago, AM MSN said:

First off, “stable” means you’re not changing anything. You continue to prescribe the medication they’re already being prescribed, likely by psych. If they’re stable and saying depressed, you refer and likely they’ll get an appointment before any medication you think to try will kick in. But if you want to try something relatively low on the side effect scale and you’re confident in your abilities, how do you know it’s not bipolar II you’re treating? How do you know you didn’t send them into full blown mania? 

So from what you’re trying to argue, FNPs have been tested and educated while in school for bipolar d/o on screening, diagnosing, and medication management? It’s not emergent for an FNP to treat schizophrenia or bipolar or even anxiety and depression - because if it were, it means they’re unstable and you send them to the ER. If they’ve had symptoms for 5 years with no treatment, why does the FNP insist on treating rather than having them wait for a referral? If it’s anxiety or depression, grab an SSRI and a referral, but why are we even talking about anything beyond this? 

Same point you just made with derm - it’s not an emergency, so stay in your lane. Which was exactly my point - it’s not necessary in the moment, and even if I’m trained and confident to do it, it’s not my scope, so WHY in the world would I do it? 

Im not sure why you guys are having such a hard time with this and now you’re insulting the PMHNP profession which is childish. I could give very specific information on the awful things I’ve seen FNPs do in the 20 years of my career, but insult an entire profession won’t make my point more credible. 

Despite having no formal training in the area, even though it says you must be trained in school and then tested on the subject in your certifying boards in the documents I provided, you INSIST it’s still your scope because it doesn’t share minimum here. That’s a scary thing and it makes sense why when I get a patient from PC I’m constantly changing the mess they made. You’re doing far more harm, including many MDs and DOs who claim to have experience in the area. 

This was a link that didn’t share earlier from the BON - notice “Has the nurse completed the necessary education to safely perform the activity, intervention or role?” Followed by, “Is there documented evidence of the nurse’s current competence (knowledge, skills, abilities, and NO judgments) to safely perform the activity, intervention or role?” “Would a reasonable and prudent nurse perform the activity, intervention or role in this setting?” Because these are the questions you get asked in a court of law and if it’s no to any of the 3, you’re guilty for practicing outside of your scope. If you cannot furnish a PMHNP certificate and you get called into court, it’s your license and at the very minimum your insurance rates just went up. Again, this is bad advice and it’s your license, people.

https://boards.bsd.dli.mt.gov/_docs/nur/sp_model.pdf

You make it sound like an outpatient FNP can’t even start a new antidepressant for gad or mdd ?. I do agree with the points that if it’s unchanged over 5 years then it can wait but usually something prompts them to seek medical attention. 
 

but there is a subset that falls between not sick enough for inpatient admission but too sick to wait on psych. 
 

for gad and mdd those are well within the scope of pretty much any pcp to treat unless it is complicated, even an FNP/PA. 
 

I do vaguely remember FNP board prep and the actual exam testing on bpd. Is it a good idea to treat it as the primary as an FNP? No. But they can screen, diagnose, initiate treatment in select circumstances and hand off to psych. 
 

and how to tell apart from bpd2? I mean most psych diagnoses are just a list of criteria, not much different from most run of the mill diagnoses. Most anyone past the second year of med school has these criteria memorized, it’s not rocket science. 

[Guest603994]

1 hour ago, Tegridy said:

You make it sound like an outpatient FNP can’t even start a new antidepressant for gad or mdd ?. I do agree with the points that if it’s unchanged over 5 years then it can wait but usually something prompts them to seek medical attention. 
 

but there is a subset that falls between not sick enough for inpatient admission but too sick to wait on psych. 
 

for gad and mdd those are well within the scope of pretty much any pcp to treat unless it is complicated, even an FNP/PA. 
 

I do vaguely remember FNP board prep and the actual exam testing on bpd. Is it a good idea to treat it as the primary as an FNP? No. But they can screen, diagnose, initiate treatment in select circumstances and hand off to psych. 
 

and how to tell apart from bpd2? I mean most psych diagnoses are just a list of criteria, not much different from most run of the mill diagnoses. Most anyone past the second year of med school has these criteria memorized, it’s not rocket science. 

Keep in mind I work with argumentative, irrational people every day - your laughing emojis don’t faze me, but if you read my post, you could see I wrote, “grab an SSRI and a referral.” I collaborate with FNPs often and I can tell you that many are not aware of their scope, so this is definitely not just an issue here. It’s something like a quarter of BON investigations are due to scope creep, as the AMA calls it, where NPs are going outside of their SOP. This is exactly the case when you blur the lines here and say sure go ahead and treat as you see fit until they’re unstable, THEN send them to a specialist. That’s silly.

And I can tell you, they don’t need to be going inpatient in order to go to the ER to ensure safety. I’m not sure why you continue to say that - if they’re unstable, an FNP does not treat and you send them to the ER if they can’t safely wait for a referral. The ER doc consults psych and treats accordingly so they can stabilize until they see psych.

Heres a great example that only happened last week: PCP refused to give propranolol to a pt c/o situation anxiety D/t SBP in the 90s. They gave a couple pills of low dose benzo instead. Pt fell in the middle of the night and had a head lac that resulted in multiple other costly interventions. They saw psych and psych immediately prescribed propranolol because they met criteria. This happens often where PCP is acting outside of their SOP and/or not collaborating on “stable anxiety” and making poor medication choices based on their experience, rather than referring, or better yet, consulting. It’s not rocket science, but FNP school isn’t medical school, so why even compare the two? And if it’s “not rocket science” and “just a list of criteria,” then why are psych providers dealing with this same ridiculous situation all day every day? A lot of incredibly insulting things are being said about the PMHNP profession as a whole here, I’m just shocked at how poorly you think of fellow NPs  

Just because you don’t like PMHNP schools, it doesn’t mean they don’t get tons of OJT or CEUs specific to their specialty every single day once employed. An FNP has a very generalized scope where they need to know enough about a lot and are not required to know the many nuances of psychiatry. Why should they?

Plus, you don’t need to guess what the criteria is for FNP school related to psychiatry - I listed it above and it says nothing about bipolar FYI so good luck to the FNP who gets called to the stand there. 

[Guest603994]

1 hour ago, Tegridy said:

You make it sound like an outpatient FNP can’t even start a new antidepressant for gad or mdd ?. I do agree with the points that if it’s unchanged over 5 years then it can wait but usually something prompts them to seek medical attention. 
 

but there is a subset that falls between not sick enough for inpatient admission but too sick to wait on psych. 
 

for gad and mdd those are well within the scope of pretty much any pcp to treat unless it is complicated, even an FNP/PA. 
 

I do vaguely remember FNP board prep and the actual exam testing on bpd. Is it a good idea to treat it as the primary as an FNP? No. But they can screen, diagnose, initiate treatment in select circumstances and hand off to psych. 
 

and how to tell apart from bpd2? I mean most psych diagnoses are just a list of criteria, not much different from most run of the mill diagnoses. Most anyone past the second year of med school has these criteria memorized, it’s not rocket science. 

Additionally, you incorrectly mentioned earlier that it depends on what the FNP’s attending can do - this is not correct for the APRN scope:

”APRN scope is not determined by the setting in which the APRN practices.  The focus is on what it is the APRN is doing – what care are they providing and what care are they managing, and, for what population including level of acuity.“ They go on to state you must be certified in the area you are practicing. THIS IS DIFFERENT THAN THE SOP FOR AN MD. You’re obviously giving incorrect information when you share your opinion, so again, the nurse who has further questions should ask their BON and not someone who claims to be a physician online who also said they prefer hiring PAs over NPs ?

[Tegridy]

On 12/18/2022 at 1:06 PM, AM MSN said:

Additionally, you incorrectly mentioned earlier that it depends on what the FNP’s attending can do - this is not correct for the APRN scope:

”APRN scope is not determined by the setting in which the APRN practices.  The focus is on what it is the APRN is doing – what care are they providing and what care are they managing, and, for what population including level of acuity.“ They go on to state you must be certified in the area you are practicing. THIS IS DIFFERENT THAN THE SOP FOR AN MD. You’re obviously giving incorrect information when you share your opinion, so again, the nurse who has further questions should ask their BON and not someone who claims to be a physician online who also said they prefer hiring PAs over NPs ?

Except that most of the scope docs list most everything or paint broad generalizations of what can be treated leaving much for interpretation (looking at FNP certification which seems to include management of most everything). Thus much of what they can and can’t do is determined by the attending. Though we are seeing decreasing numbers of FNP in the hospital which is good since they usually have no training for that. 
 

but for outpatient they provide broad and vague terminology that can technically be interpreted in many ways. Mostly Jargon to protect the nursing board. On the top it even says “not limited to”

 

and for the case we have all seen garbage medicine, it is just much more often seen from mid levels.  Other than that we are just talking past each other according to your responses which aren’t even addressing what I said before. I will end saying fnps treating psych conditions is the least of my worries since we have FNP in the unit writing for cardiac drips, but I digress there are many things in healthcare that so not make sense. The length and pathways for NP training come close to taking the cake though. 

[KetafolDNP, DNP, CRNA, NP]

My FNP program had a semester of "primary care psychiatry".  We used a textbook aptly named "Primary care psychiatry, 2e" by Robert McCarron. Great text. Also helps answer questions of when to refer, when it's reasonable to manage in primary care, and when it's reasonable to initiate therapy and refer to psych. I think it's important to start therapies for GAD and MDD promptly, especially if there is delay in specialty care . It may be reasonable to start treatment for other conditions as the FNPs training and comfort allow, while generating psych referral/follow up if you think that's the safest option for the patient. As always our first obligation is to rule out systemic illness as a cause of psychiatric symptoms.