looking for some input from psych nurses

Nurse Ratched, RN · Apr 15, 2006

It's the psychiatrist's or other provider's job to assign a diagnosis. If there is no Axis 2 at time of admission, then a simple "deferred" could be inserted, for the psych to attend to later. A nurse (non-advanced-practice, I mean) doing so would constitute exceeding our scope of practice.

elkpark · Apr 15, 2006

You're correct; diagnosing is outside the scope of your practice, and needs to be done by someone who is licensed/credentialed to function independently -- like, oh, say, the physician who is admitting the patient to the hospital. That's what s/he is getting paid for!!! If you are consulting (by telephone, say) about the admission with a doc or therapist who is an independent provider and s/he tells you what to write down, that's ok, of course (the same as taking a telephone or verbal order for meds, etc.).

You are consulting with someone about admissions, right? Surely you don't have admitting privileges, and are not expected to decide independently whether people need to be admitted to a psych unit?? I'm guessing that your program director and administrators are probably not nurses (typical in psych settings), and probably not familiar with specifics about your scope of practice. You need to be v. careful and vigilant about protecting your license, because no one else is going to do that for you. :uhoh21:

It's unfortunate that you've been put in this difficult and risky situation as a (relatively) new graduate. Is this a private-for-profit facility? In my experience as a surveyor for my state and the Feds, those were the places most likely to play fast and loose with the rules and accepted standards of practice (as you describe here) ...

Lemming Tamer · Apr 16, 2006

Nurses should never determine (or be asked to) a medical diagnosis!

I'm guessing that your program director and administrators are probably not nurses (typical in psych settings), and probably not familiar with specifics about your scope of practice. here) ...

I recently found out the new administrator/"dictator" of the psych facility where I work is a recreational therapist!! She is micro-managing every deparment and unit. We're about to lose the few good staff members that survived the corporate takeover 2 years ago.

(elkpark gave me an idea for a new topic!)

karynfrances · Apr 17, 2006

we are having similar problems in our unit. managers are telling nurses to diagnose patients even though it is outside of our scope of practice and our nursing body has told us and them this. makes you feel that the work we are supposed to be doing is devalued and the added pressure makes one wish to get out of nursing.

CharlieRN · Apr 21, 2006

i am a recent grad been working at psych hopital since nov. i recently took a position in the admissions dept. the program director expects me to make Axis diagnosis on new admissions. what i am wondering is this allowed in my scope of practice? i thought a nurse could not diagnos, i asked the adminstrator on duty he said it is not illegal but prob inappropriate. any one have advice whether i should do this

You have discribed my job. I make psych dx all the time. BUT, as I frequently tell the patients, "I'm a nurse, I don't make the diagnosis, I just suggest it to a sleepy psychiatrist at 3 am. " In general, since they know me and I am the person on the scene with the patient, I don't get a lot of arguements. I am always carefull to present my dx as a suggestion and request that the psychiatrist offer any changes he wishes based on the case as I have presented it to him/her.

You are practicing in an "extended role", under "institutional liscensure." That is your employer, has put themselves on the line that you are able to perform the duties they have asked of you, knowing full well what your qualification and liscensure is. You have not misrepresented yourself.

Your employer should have clinical supervision available to you to help you improve your compentence.

Thunderwolf, MSN, RN · Apr 22, 2006

Many years ago when I worked in community mental health, the term "diagnostic impression" was used to describe this function by non physician staff. Charlie is correct.

margarita · May 21, 2006

I work on an acute inpatient unit. I live in B.C. Canada. On our unit we use the DSM-IV extensively and are expected to know the diagnostic criteria for the various disorders and to come up with a diagnosis for our pts. The Dr. does the definative Dx, and we will have a provisional Dx prior to interviewig the pt., but we do come up with a Dx based on the target symtoms. Some pts. are very straight forward as to what their Dx is. The other more complicated presentations require team discussion and dissecting the symtoms til you come up with a workable diagnosis. Our Team Leader is brilliant and a great resource for us as we become comfortable with this universal Manual. It is not considered out of our scope of practise to figure out what a pts. Dx is. If the nurse who posted the original post, as a fairly new grad doesn't feel comfortalbe with coming up with a Dx then they should be provided with suppport and learning opportunites to acqurie this skill. To me it seems a given that you would be able to diagnose your patient. You need to know what you are treating. We have the knowledge, why wouldn't we use it? Cheers and happy reading! (DSM-IV)

spaniel · May 23, 2006

Elkpark, sorry to put you on the spot here. But I am curious as to your response. Indeed, is it legally acceptable to consider "institutional licensure" as CharlieRN suggested?This is with regards to the previous post written by a person who is asked to supply An Axis I dx upon admission, I believe. It's my understanding that this person is not an advanced nurse practitioner or CNS.

I also have seen this done in psych,especially in community mental health settings. However, I do not believe institutional licensure grants one the priviledge (at least legally). Now please, I am not suggesting in the least that many excellent psych nurses do not have the capacity to diagnose. That's a separate issue.

I am also seeing a trend where the (non-advanced )RN is suggesting specifici psychotropic meds/dosages In WRITING to the primary care M.D.. Again I am not suggesting that many a good psych nurse is not good (if not better) than the PCP but from a legal standpoint I do question this. I see this in rural areas especially.

CHATSDALE · May 23, 2006

patients are usually not admitted cold...they are referred per other facility or primary md with a dx i assume that they can be admitted under those guidelines until they are evaluated by someone with the expertise and the authority to do so

CharlieRN · May 23, 2006

Elkpark, sorry to put you on the spot here. But I am curious as to your response. Indeed, is it legally acceptable to consider "institutional licensure" as CharlieRN suggested?This is with regards to the previous post written by a person who is asked to supply An Axis I dx upon admission, I believe. It's my understanding that this person is not an advanced nurse practitioner or CNS.
I also have seen this done in psych,especially in community mental health settings. However, I do not believe institutional licensure grants one the priviledge (at least legally). Now please, I am not suggesting in the least that many excellent psych nurses do not have the capacity to diagnose. That's a separate issue.
I am also seeing a trend where the (non-advanced )RN is suggesting specifici psychotropic meds/dosages In WRITING to the primary care M.D.. Again I am not suggesting that many a good psych nurse is not good (if not better) than the PCP but from a legal standpoint I do question this. I see this in rural areas especially.

I see the "institutional Licesure" of the type I act under as perfectly legal because my dx is never acted upon in any way until after it is accepted by the on call MD and further is only valid within my facility. I develop a proposed dx and present it at the end of my case presentation. The on call MD either accepts it, modifies it or rejects it and replaces it with something more to his\her liking. At that point it his or her dx.

Regarding medications suggested to a non psychiatrist MD by a nurse working as a psych specialist; I see that as a bit trickier. I've done it, but rarely. The responsiblity of ordering the medication remains with the physician, but it is not unreasonable for a non specialist to seek information from someone more familiar with the meds involved. If I feel comfortable giving information I would be as willing to give it in writing as any other way. Frequently physicians who are not working in psych don't use the meds in "psych appropriate" doses. Generally: PCP's under dose, ER physicians sometime use a heavy hand. Both are understandable in the special circumstances of their paractice. PCP's prescribe meds that the patient uses unsupervised. ER Docs expect to be right there on hand while the med takes effect. I once had an ER send me a woman who had been disruptive in their ER. She was supposed to be a voluntary admit but they had give her Ativan 5mg IM before loading her into the ambulence. When she got to me she could not respond to painful stimuli. A patient can't get into our facility without signing an informed consent for treatment. I sent her right back.

elkpark · May 23, 2006

I see the "institutional Licesure" of the type I act under as perfectly legal because my dx is never acted upon in any way until after it is accepted by the on call MD and further is only valid within my facility. I develop a proposed dx and present it at the end of my case presentation. The on call MD either accepts it, modifies it or rejects it and replaces it with something more to his\her liking. At that point it his or her dx.

Spaniel, "institutional licensure" is not a term I have ever heard before, so I have no opinion or comment -- except to say that I, personally, would never consider doing something I knew to be outside the scope of practice for my license on the strength of an employer telling me it would be okay for me to do so because they're "covering" me (in fact, I've flatly refused to do so on several occasions). I've seen 'way too much over the years to depend on any employer to protect my interests, and it ain't gonna be ME that's left hung out to dry when the doo-doo hits the fan... :uhoh21:

However, the practice CharlieRN is describing is common and the same thing I did for many years as a staff nurse; of course experienced psych nurses have opinions about client dxs, and offer/suggest these when reporting to docs on new clients -- but the official, formal dx comes from the doc (CNS, NP, etc.). Independently diagnosing a client's psychiatric disorder is just as far outside the scope of practice for a generalist RN as diagnosing medical disorders in med/surg settings is (in the US, that is).

However, this is a fine legal point that is often lost on the non-nurse/non-physician administrators that one encounters so often in psych settings ... :rolleyes:

I'm still curious about the answer to the question I asked in my original response to the OP -- surely there must be a physician (or someone with admitting/attending privileges) who is responsible for admitting the client to the facility, with whom s/he (the OP) could/should be consulting re: dx?? People cannot be admitted to inpatient healthcare facilities of any kind, psych or otherwise, without a physician (or other appropriately licensed provider) being responsible for admitting them and directing the care provided -- the CMS (Federal govt), JCAHO, and state rules require that. So, who/where is the admitting/attending doc responsible for the people the OP is assessing in the facility's assessment center, and why wouldn't that person be readily available to consult with the OP (by telephone, at least) about (need for) admission and admitting dx??? That's the doc's JOB, and what s/he is getting paid the big bucks for ...