Impact Of Nurse Practitioner Scope Of Practice Regulation .
Impact of Nurse Practitioner Scope of PracticeRegulation on Psychiatric Mental Health NursePractitioner PracticeBethany Phoenix, PhD, RN, CNS, FAANSusan Chapman, PhD, RN, FAANChristopher Toretsky, MPHNCSBN Scientific SymposiumOctober 24, 2018
Background§ Shortage of BH providers, esp.prescribers§ PMHNPs have skill set to provideneeded services§ State restrictions on scope of practicemay limit optimal use of PMHNPs§ PMH-APRN practice associated withpositive patient experiences &outcomes of SAs/HGDWMapGallery BHPR HPSAs MH.pdf2NCSBN Scientific SymposiumOctober 24, 2018
Study Aims1. Determine how state scope of practiceaffects PMHNP practice and educationin states with different levels of NPautonomy2. Identify effects of NP practicerestrictions on access to behavioralhealth services in selected states.3NCSBN Scientific SymposiumOctober 24, 2018
Methods§ Selected 5 states with varying levels ofNP autonomy§ Snowball sampling§ Data sources Qualitative interviews Document reviews§ Thematic N Scientific SymposiumOctober 24, 2018
Methods(cont.)Informants§ 94 informantsProf Org3%Psychiatrist8% 14-28/stateRegulators11% Group & individualinterviewsAgency staff13%PMHN faculty16%§ 40 organizations 6-10/statePMHCNS4%PMHNP45%5NCSBN Scientific SymposiumOctober 24, 2018
Oregon§ Independent practice since ‘70s§ Prescriptive authority 1979§ Insurance parity for NPs in PC & BH§ Private/group practices common§ PMHNP student placements limited6NCSBN Scientific SymposiumOctober 24, 2018
Colorado§ Law changed to allow FPA forAPRNs in 2015§ Requires1000 post-grad hrs.supervised prescribing beforegranted independent prescriptiveauthority§ Must keep “articulated plan” on file Professional development Consultation QA§ PMHNPs can’t release legal holds7NCSBN Scientific SymposiumOctober 24, 2018
Massachusetts§ Independent practice except forprescriptive authority—collaborate w/MD§ PMHCNS scope of practice essentiallysame as PMHNP§ APRNs required to have log ofcontrolled substance prescriptionssigned by collaborating MD in 96 hrs.8NCSBN Scientific SymposiumOctober 24, 2018
North Carolina§NPs jointly regulated by BON &BOM§APRNs required to havecollaborative practice agreementw/ MD§Avg. cost of MD collaborator 1500-3000/mo.§No limit to how many NPs MDcan supervise9NCSBN Scientific SymposiumOctober 24, 2018
Illinois§ January 2018: Legislation takes effectgiving full practice authority to APRNswith 4000 hrs. supervised clinicalexperience§ APRN must practice in collaboration w/MD until meets qualifications for FPA§ Can prescribe Schedule II-Vindependently, except for benzos &opioids§ Implementing regulations not yetpublished10NCSBN Scientific SymposiumOctober 24, 2018
Impact of Scope of Practice Regulation11NCSBN Scientific SymposiumOctober 24, 2018
Practice Model§ Psychiatric assessment & medicationmanagement most common rolefunctions§ Full practice authority states More freedom to develop nursing-basedmodels of care Mixed payor sources More PMHNPs in leadership§ Restricted states Expense of MD collaborator & difficulty withcollaboration arrangements a significantimpediment to private practice Understanding of NP regulations verymixed12NCSBN Scientific SymposiumOctober 24, 2018
MD Supervision/Collaboration: Positives§“I wouldn’t feel comfortablepracticing at this stage of my careerwithout having someone who is moreexperienced who is required toanswer my questions.”§Collegial support§Helpful for new grads13NCSBN Scientific Symposium§“I would get MD consultation evenif it wasn’t required.”October 24, 2018
MD Supervision/Collaboration: Negatives14Justifies unequal pay forsame workInstitutionalizes inequitableprofessional relationships“The laws & regulations are acontrol issue to make sure thatNPs don’t get compensated asmuch as the doctors. Once youget rid of supervision, you’llhave more clout with theinsurance companies and getreimbursed at a higher rate.”“The model of ‘mandatorysupervision’ is challengingbecause it takes a lot of timeand you can never ‘proveyourself.’ Once you have enoughexperience, you should no longerneed supervision.”NCSBN Scientific SymposiumOctober 24, 2018
EconomicEconomicExploitationExploitation“The Carolina Partners Nurses Supervision ProgramMost Carolina Partners’ psychiatrists supervise one or more nursepractitioners or PAs. Because North Carolina’s supervision rules are modest,money earned from supervising good, experienced nurses or PAs is almostpassive income for the doctor. Psychiatrists earn from 10,000.00 to 15,000.00 per nurse, so a doctor supervising four full-time nurses wouldearn up to 60,000.00 per year in extra -without-bosses/ Retrieved 11/16/201715NCSBN Scientific SymposiumOctober 24, 2018
Collaboration Negatives16Difficulty findingcollaborating MDCollaborating MD lessknowledgeable“If you want to open a privatepractice, you may have a hardtime finding a supervisingpsychiatrist. My real dream isto open a practice in X andwork 2-3 days a week, butwould be impossible to find asupervisor.”§“ I’m being assigned to a brand-newpsychiatrist, mostly so I can mentorher. This is not the first time it’shappened.”NCSBN Scientific Symposium§ PMHNP with specialty in perinatalMH disorders—none of her MDsupervisors knew as much about itas she didOctober 24, 2018
Collaboration NegativesNo supervision actually provided"The relationship with the supervisor I hadbefore my current one was bogus. I couldbarely track her down. Besides, I didn’thave anything to talk to her about becauseI've been in practice for so long."17NCSBN Scientific SymposiumOctober 24, 2018
MD Supervision/Collaboration: Negatives§Confusion about regulations§Agency policies sometimes morerestrictive than required by law§Inefficient: wastes MD & PMHNPtime“Per [health system] bylaws, all NP noteshave to be co-signed. The physicians hateit—they can’t keep up with reading all thenotes.”18NCSBN Scientific SymposiumOctober 24, 2018
If the goal is consultation to provide quality practice .§ What we learned Supervision ¹ Consultation Supervision did not always occur with required frequency Supervisor maybe not in similar clinical practice area Often no choice in who was supervisor or supervisee§ Consultation worked best when Matched in practice and location Just in time consultation Choice of collaborator True peer collaboration, sharing knowledge and practice challenges19NCSBN Scientific SymposiumOctober 24, 2018
Conclusions§ APRN scope of practice legislationbased on stakeholder interests, notevidence§ Lack of standardization leads toconfusion§ Requirements for MD supervision Add to cost of care without improvingquality Reduce access to care Justify unequal reimbursement20NCSBN Scientific SymposiumOctober 24, 2018
References1. Health Resources & Services Administration. Health professional shortageareas—mental health map. Retrieved SAs/HGDWMapGalleryBHPR HPSAs MH.pdf2. Illinois Health & Hospital Association. (2017, June). HB 313 - NursePractice Act (225 ILCS 65/), Public Act 100-0513, Summary. Retrievedfrom x on August 6,2018.3. Phoenix BJ, Hurd M, Chapman SA. Experience of psychiatric mentalhealth nurse practitioners in public mental health. Nurs Adm Q.2016;40(3):212–224. https://doi.org/10.1097/NAQ.0000000000000171.4. Rudner, N. & Kung, Y.M. (2017). An assessment of physician supervisionof nurse practitioners. Journal of Nursing Regulation, 7(4), 22-29.21NCSBN Scientific SymposiumOctober 24, 2018
Impact of Nurse Practitioner Scope of Practice Regulation on Psychiatric Mental Health Nurse . of nurse practitioners. Journal of Nursing Regulation, 7(4), 22-29. 21 NCSBN Scientific Symp
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