There’s a lot of gray area surrounding specialties for nurse practitioners. Unlike physicians, who study very specific areas of medicine, as NPs our specialties are pretty general. ‘Acute Care’ and ‘Family’ are about as specific as it gets for us in most educational institutions. Instead, we hone our areas in practice on the job with training from an employer.
As a result of our broad training, the scope of practice for nurse practitioners is loosely defined. Overall, laws don’t name specific types of patients we’re allowed to treat or the settings in which we’re allowed to work. Scope of practice regulations are ill defined and generalized. So, where do you draw the line if you’re a nurse practitioner interested in working in a specialty setting?
I get this question often, particularly from family nurse practitioners like myself, as we’re trained with a broad foundation. A number of FNPs ask if they’re allowed to work in psychiatric settings. Admittedly, there’s no hard and fast answer to this question. Rather, there are a number of guiding laws as well as professional principles and opinions. If you’re an FNP looking to work exclusively in the psychiatric setting, here’s what you’ll need to consider:
Scope of Practice
As nurse practitioners we’re constantly warned to stay within our scope of practice. But, what does this really mean? Regulatory organizations and state laws don’t post a comprehensive list of diagnoses we’re allowed to make or procedures we’re allowed to perform (with a few exceptions).
In general, there are a few requirements for inclusion in an NP’s scope of practice:
- Legal – the law allows the NP (or does not disallow) the NP to perform the action or treat the subset of patients. For example, diagnosing and prescribing are typically named as specific actions the NP is permitted to perform in state scope of practice laws.
- Training – the NP is educated/trained in the types of services he/she is providing. For example, suturing is within the scope of practice for nurse practitioners. However, if you have never been trained to suture, you shouldn’t begin doing so without instruction.
Takeaway: Know your state’s scope of practice laws for nurse practitioners (although they are unlikely to give you specific answers to most questions). And, if you haven’t been trained to do something or to treat a subset of patients, don’t do so until you have the proper training.
While the law doesn’t usually address NP education and how it plays into practice setting, there are some professional norms to consider. Family nurse practitioners, for example, don’t spend time learning about management of patients in the ICU. So, practicing in the ICU with an FNP degree would be considered working outside of one’s scope of practice in most cases. Adult nurse practitioners are not educated about diagnoses and management of pediatric patients so shouldn’t work in pediatric settings. While not specifically stated in law, these are generally understood professional and education standards.
Things get fuzzy when we talk about situations like FNPs working in psych. Family nurse practitioners are educated about psychiatric illnesses as part of their basic education.
Takeaway: Professional/education norms may not be specifically named in state law but they should be considered in making a specialty decision.
Most states require that nurse practitioners be supervised by or collaborate with a physician. This collaborative agreement is outlined in a document signed by both parties and filed with the state board of nursing. In some states, the collaborating physician must be certified in the same specialty in which the NP is practicing and/or certified. So, if you’re a FNP interested in working in a psychiatric facility, state law may prohibit this on the grounds that your collaborating physician cannot be a psychiatrist. Unless the facility employs a family physician also working in psych, you may be out of luck.
Takeaway: Know the collaborative requirements in your state, specifically as it relates to the requirements for the physician that can be named as a collaborator or supervisor.
So, can an FNP work in psych?
As long as you’ve got experience or training in the specialty, have a collaborating physician lined up, and are in compliance with state scope of practice laws, you’re probably in the clear. This is especially true if you’re treating less complex psychiatric patients or working in conjunction with a family practice setting. If you’re treating psychiatric patients in the inpatient setting or with complex diagnoses, you’ll want to consider getting your PMHNP degree. While legally you might be OK, if your actions are ever called into question, it could be determined that you aren’t following standard professional practice norms. Many FNPs that transition to psych simultaneously enroll in a post-masters program to formally include the specialty in their credentials.
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