FNP working in psych inpatient

Jules A, MSN · Aug 28, 2018

Did you think to ask if it is medical management or psych management? That would be your answer. As you alluded to always remember many employers could care less if we working within our scope so it is up to us to be responsible for our patients and our licenses.

Cindy-20 · Aug 28, 2018

I didn't at the time. Do I go in for the interview and get clarification or forget about it all together?

elkpark · Aug 28, 2018

I've worked in inpatient psychiatric units that had an FNP on staff to manage (only) the medical issues on the unit (of which there are always plenty!). That model worked v. well. On the other hand, be aware that physicians, including psychiatrists, often don't know how advanced practice nursing works -- he may believe that you would be "fine" working as a psychiatric provider with "sufficient training," but not realize that the state BON wouldn't permit that (if that's the case; just an example). What does your state BON say about a situation like this? Some are still fairly permissive, but others are quite strict about what settings and roles people can work in based on their education and certification.

IMO, it can't hurt to go the interview and find out what they're offering.

Cindy-20 · Aug 28, 2018

I'm in MA. I sent an email to the BON as I was unable to find specifics.

Cindy-20 · Aug 28, 2018

This is the response I received and now seem to be more confused...

The Massachusetts Board of Registration in Nursing (Board) is created and authorized at General Laws (G.L.) chapter 13, sections 13, 14, 14A, 15 and 15D, and G.L. c. 112, ss. 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education, and the issuance of advisory rulings. The Board has legal authority to promulgate regulations that govern nursing practice and nursing education. These regulations are contained at 244 CMR 3.00 - 9.00, and are available on the Board's website (Nursing - Health and Human Services - Mass.Gov) for your review and reference.

The scope of Advanced Practice Registered Nurse (APRN) practice is reflective of standards for the provision of health care services to individuals throughout the lifespan, including health promotion, disease prevention, health education, counseling and making referrals to other members of the health care team, as well as the diagnosis and management of acute and chronic illness and disease. The Board authorizes APRN by clinical category - (1) Certified Registered Nurse Anesthetist (CRNA); (2) Certified Nurse Midwife (CNM); (3) Certified Nurse Practitioner (CNP); (4) Clinical Nurse Specialist (CNS); (5) Psychiatric Clinical Nurse Specialist (PCNS) - not by a specialty designation. An APRN in Massachusetts may provide health care services to individuals for which he/she has attained and maintained the competency to do so.

A personal recommendation would be for each APRN to maintain a portfolio demonstrating how he/she attained and maintained the competency to assess, diagnose and treat patients that are not typical to his/her certification specialty designation.

Keep in mind that payers of services may require specific certification for clinicians in order to reimburse for services.

Effective August 1, 2014, the Massachusetts Board of Registration in Nursing (Board) promulgated revised regulations governing the practice of the Advanced Practice Registered Nurse (APRN). The amended regulations at 244 CMR 4.00 are intended to reflect the enactment of new laws as well as to make the regulation of Advanced Practice Registered Nurse (APRN) practice more consistent with the national APRN Consensus Model.

The revised regulations at 244 CMR 4.00: Massachusetts Regulations Governing Advanced Practice Registered Nursing include, but are not limited to:

Clarification that guidelines are written instructions and procedures describing the methods that an APRN with prescriptive practice is to follow when managing medications. Guidelines and physician supervision are required only for the prescriptive practice of a Certified Nurse Practitioner (CNP), Certified Registered Nurse Anesthetist (CRNA), or Psychiatric Clinical Nurse Specialist (PCNS) who registers for prescriptive practice. The methods and timeframes for prescriptive review are determined by the APRN and the supervising physician. There is no physician supervision or guideline requirement for an APRN who does not register for prescriptive practice. The specifics for guideline development have changed significantly and I would suggest you review the audit tool at https://www.mass.gov/files/documents/2016/08/xx/apnaudit.pdf for a complete synopsis;

Clarification that CNM are no longer required by law at MGL c. 112 s. 80G to have guidelines or a supervising physician for any aspect of practice;

Enforces that APRNs are responsible and accountable for his or her nursing judgments, actions, and competency. A discrete scope of practice section for each category of APRN is located at 244 CMR 4.06;

Referencing M.G.L. c. 112 s.80I, which authorizes CNPs to sign or certify documents that previously only a physician could sign provided that the signature, certification, stamp, verification, affidavit or endorsement is consistent with established scope of practice standards, and does not expand the scope of practice of a CNP; and

The creation of the non-psychiatric Clinical Nurse Specialist (CNS) category of APRN practice. The CNS is not authorized to prescribe and therefore is never required to have guidelines; and

The addition of a requirement for professional malpractice Liability Insurance for all APRNs with direct patient care responsibilities.

Please be advised that the response of the Board to individual practice inquiries represent the Board's interpretation of the legal scope of nursing practice. This response is valid only in the context in which it is rendered; it does not have general applicability, as do statutes, regulations and advisory rulings.

allnurses Guide · Aug 28, 2018

A personal recommendation would be for each APRN to maintain a portfolio demonstrating how he/she attained and maintained the competency to assess, diagnose and treat patients that are not typical to his/her certification specialty designation.
Enforces that APRNs are responsible and accountable for his or her nursing judgments, actions, and competency. A discrete scope of practice section for each category of APRN is located at 244 CMR 4.06;

If you are planning to work in a role that is outside of your specialty you must be prepared to adequately defend that the role you are in falls within the scope of your training and experience.

Medical management of psych admissions while in-patient is already at the fringe of your specialty and you should think about if you have the experience and training to manage in-patient.

Psych management of psych admissions is clearly out of your specialty and (form you comments) your experience and training. It would be a big legal risk for you to practice in this role.

Also keep in mind, as a novice NP, rounding on 20 medical patients is a pretty stiff learning curve.

InquisitiveAPN · Aug 28, 2018

Just to add a different mindset, inpatient psych, in my experience, always has a FNP or similarly scoped physician round to do H&Ps and address what limited medical issues in house that may come up.

I couldn't accurately grade a DTR if my life depended on it at this point. And what's in an ear canal?

The psych folks still handle the psych stuff.

Jules A, MSN · Aug 28, 2018

I've worked in inpatient psychiatric units that had an FNP on staff to manage (only) the medical issues on the unit (of which there are always plenty!). That model worked v. well. On the other hand, be aware that physicians, including psychiatrists, often don't know how advanced practice nursing works -- he may believe that you would be "fine" working as a psychiatric provider with "sufficient training," but not realize that the state BON wouldn't permit that (if that's the case; just an example). What does your state BON say about a situation like this? Some are still fairly permissive, but others are quite strict about what settings and roles people can work in based on their education and certification.
IMO, it can't hurt to go the interview and find out what they're offering.

I agree although I wouldn't go to the interview without clarifying what role they were interested in filling. It will save everyone a lot of time if it is psych only.

Oldmahubbard · Oct 8, 2018

Insurance is unlikely to reimburse you if you are trying to do psych without the certification. With good reason.