Letter to the Editor on "Advanced Practice Nursing"

Advanced Practice Nursing

November 23, 1998
in response to Advanced Practice Nursing

Dear Editor:

I do not see the Psychiatric Advanced Practice Nurse role as so much a combination of roles, but rather as distinct from the general medical practitioner role. In my opinion it is foolish to expect one provider to be expert enough to provide services in both general medicine and psychiatry. Since I am employed as a Psychiatric NP and have filled this role for the last 6 years, I believe I have a basis from which to speak.

In Alaska, where I am licensed and employed, Advanced Practice Nurses (APNs) are licensed in their respective clinical specialty. I understand this is different from some states in which the APN is certified in a specific role such as the CNS or NP role, rather than in a clinical area.

Here in Alaska I am licensed as an Advanced Nurse Practitioner with a specialty in psychiatric and mental health services. The focus of my practice is psychiatric. I do not do physical assessments. My practice is in the public sector. My prescriptive authority is confined to drugs used in psychiatry. I am considered a primary care provider in my specialty and receive third party payment with no problem. I bill and am paid at the same rate as a psychiatrist. A part of any psychiatric assessment I do is a review of health issues. If I identify physical health concerns that need attention, I coordinate the needed treatment with the medical provider involved. I refer to all branches of medicine and my referrals are considered as valid as those of any other provider. I am not required to have a physician cosign any of my orders or prescriptions. I do not work by any institutional protocols, but use the standards in "The Treatment of Psychiatric Disorders" published by the American Psychiatric Press. I am required to provide a consultation and referral plan to the Board of Nursing. In this plan I must list sources for psychiatric and medical consultation and referral.

In my practice I routinely screen for common medical problems. I refer to a medical practitioner for treatment when this screening indicates such a referral is needed or when the medical status of the patient is unclear. My wish is to encourage the medical providers to do the same by referring to psychiatric providers when a psychiatric problem is identified. Certainly I have no issue with these medical providers prescribing one antidepressant, or to their providing emergency antianxiety medication and treatment. I only wish they would refer when these first line measures do not work.

I cannot tell you how frequently I have referrals from medical providers who have given a panoply of medications that are not effective. In these cases I am usually given little information that is of use in making a correct psychiatric diagnosis. Frequently these patients are sent to me because the patient is considered a problem or their funds have been used up. These patients often arrive disgruntled and distrustful if they arrive at all. I sometimes get the impression psychiatric medicine and services are second class, or last ditch, services. In reality these services, when provided early on, often reduce the need for extended medical tests and interventions.

What I would like to get across with this letter is that NPs with a psychiatric specialty can and do provide appropriate, vital and cost effective services that medical practitioners would be wise to offer to their patients. Psychiatric Advanced Practice Nurses need to focus on providing psychiatric services, rather than diluting their contribution by offering both psychiatric and general medical services.

Jean Richards, RN, NP
Iliuliuk Family and Health Services, Inc.
Community Mental Health Center, Alaska