ANCC PMHNP CHAPTER 2
PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER ROLE, SCOPE OF
PRACTICE, AND REGULATORY PROCESS
Advance Directives - ANS-Advance Directives
*Durable power of attorney for health care. Also known as healthcare proxy
** Legally binding in all 50 states
** Designates, in writing, an agent to act on behalf of a person should he or she become unable
to make healthcare decisions
** Not limited to terminal illness; also covers other aspects of illness, such as making financial
decisions during a person's illness
** Should be considered as an aspect of relapse planning for clients with chronic psychiatric
disorders
* Living will: Document prepared while client is mentally competent to designate preferences for
care if client becomes incompetent or terminally ill
** Not legally binding in all states
\All nurse practitioners upon graduation are expected to meet - ANS-NURSE PRACTITIONER
ADVANCED PRACTICE CORE CONTENT
a set of core competencies
Specialty competencies, such as the Psychiatric-Mental Health Nurse Practitioner
Competencies, are then built upon these core competencies (NONPF, 2013).
\Benefits of Disclosure - ANS-Benefits of Disclosure
* Able to request reasonable accommodations
* Opportunity to have a job coach come to the worksite and communicate directly with employer
* Employee can involve an employment service provider, employee assistance program, or
other third party in the development of accommodations.
* Easier for employee to come to work during an exacerbation of symptoms
* May help with the recovery process
* Allows coworkers to offer personal support
* May empower another employee to disclose
\CASE STUDY 1
Karen Harris is a newly graduated PMHNP. She worked as a psychiatric nurse for 5 years
before going to graduate school. She is considering a job at the local community mental health
center.
,The director of the center has told her that her role would consist of seeing mainly adult clients
with serious, chronic, and persistent mental illness. On occasions when the psychiatrist is
"busy," Ms. Harris is told she may be expected to see a few children in addition to adults. The
director expects Ms. Harris to provide medication management to well-known clients and
occasionally to assist in diagnostic evaluations of new clients or clients in crisis. He also expects
that she will "from time to time" meet the emergent medical
needs of clients who have limited access to primary care providers, including the routine,
ongoing care of nonpsychiatric disorders such as diabetes, hypertension, and chronic pain. Ms.
Harri - ANS-ANSWERS TO CASE STUDY DISCUSSION QUESTIONS
Case Study 1
1. The key word here is "legally." Professional standards and scope of practice documents
suggest what is reasonable and prudent practice. Professional nursing organizations will
provide information on what is seen as acceptable educational preparation for practice.
However, the individual legislative regulations of each state
determine what constitutes legal practice for each individual PMHNP.
2. The Nurse Practice Act and related legislation of the state in which she practices will
delineate the legal boundaries of her practice.
3. Professional standards and scope-of-practice documents suggest what is reasonable and
prudent practice. The individual legislative regulations of each state determine what constitutes
legal practice for each individual PMHNP.
4. Professional nursing organizations provide information through a Scope and Standards
document about what is seen as an acceptable practice role for PMHNPs, but the PMHNP's
practice is ultimately guided by the individual state's Nurse Practice Act.
5. Any client, including a psychiatric client, has the right to refuse treatment. Ms. Harris is legally
and ethically bound to honor the client's rights.
6. Ms. Harris must meet the legal standard in the state where she practices to treat a client
against his or her wishes. This usually entails performing the legal task of committing a client
and in most states, ensuring that the following criteria are met:
ZZ The person has a diagnosed psychiatric disorder
ZZ The person is unaware or unwilling to accept the nature and severity of disorder
ZZ As a result of a mental disorder, a person is harmful to self or others
ZZ As a result of a mental disorder, a person cannot take care of his or her basic needs of food,
clothing, and shelter
7. A durable power of attorney
\CASE STUDY 2
A PMHNP working in a rural mental health clinic is asked by a women's clinic to evaluate Ms.
M., a 35-year-old female. Ms. M. insists she is not depressed, but that she has been feeling
understandably
distressed because she was fired from her job for excessive absenteeism related to "head,
neck, and back pain." Ms. M. has difficulty falling and staying asleep, wakes up feeling tearful,
and doesn't want to get out of bed. She has become socially isolative and spends hours sitting
in front of the television. She has been taking 50 mg of amitriptyline for the past 6 months. The
medication has been prescribed by a physician's assistant at a women's clinic. She was last
, seen at the women's clinic 4 months ago. After evaluating Ms. M., the PMHNP decides that she
meets criteria for major depression. He decides to continue the amitriptyline but
increases the dose.
1. How should the PMHNP explain his rationale fo - ANS-ANSWERS TO CASE STUDY
DISCUSSION QUESTIONS
Case Study 2
1. The PMHNP must discuss the treatment plan in the context of the client's psychiatric
symptoms. Without trying to convince the client that she has major depression, the PMHNP can
discuss how chronic pain may have led to the distress she is currently experiencing and that the
medication may address many of her distressing
symptoms. He will also need to address the potential side effects from this tricyclic
antidepressant, and the usual course of treatment in terms of dosing and timeline.
2. Yes, if the PMHNP is using the medication to target the client's depressive symptoms and if
he believes the benefit-to-risk ratio is reasonable in this instance, it is reasonable for the
PMHNP to continue the medication and adjust the dose. The PMHNP must do all the relevant
medical tests to prescribe this medication.
\Commitment - ANS-Commitment
* Process of forcing a person to receive involuntarily evaluation or treatment
* Process may differ from state to state
* Basic criteria include
** Person has a diagnosed psychiatric disorder,
** Person is harmful to self or others as a consequence of the disorder,
** Person is unaware or unwilling to accept the nature and severity of the disorder, and
** Treatment is likely to improve functioning.
* Involuntary admission
** Admission to a hospital or other treatment facility against the person's will
** Clients maintain all civil liberties except the ability to come and go as they please
** Amount of time clients can be kept against their wishes varies by state
* Voluntary admission
** Admission to a hospital or other treatment facility that a person desires or agrees to
** Client maintains all civil liberties
** Client consents to potential confinement within the structure of a hospital setting
\Competency - ANS-Competency
*A legal, not a medical concept
*A determination that a client can make reasonable judgments and decisions regarding
treatment and other health concerns
*A person is considered competent until a court rules the person to be incompetent.
PSYCHIATRIC-MENTAL HEALTH NURSE
PRACTITIONER ROLE, SCOPE OF
PRACTICE, AND REGULATORY PROCESS
Advance Directives - ANS-Advance Directives
*Durable power of attorney for health care. Also known as healthcare proxy
** Legally binding in all 50 states
** Designates, in writing, an agent to act on behalf of a person should he or she become unable
to make healthcare decisions
** Not limited to terminal illness; also covers other aspects of illness, such as making financial
decisions during a person's illness
** Should be considered as an aspect of relapse planning for clients with chronic psychiatric
disorders
* Living will: Document prepared while client is mentally competent to designate preferences for
care if client becomes incompetent or terminally ill
** Not legally binding in all states
\All nurse practitioners upon graduation are expected to meet - ANS-NURSE PRACTITIONER
ADVANCED PRACTICE CORE CONTENT
a set of core competencies
Specialty competencies, such as the Psychiatric-Mental Health Nurse Practitioner
Competencies, are then built upon these core competencies (NONPF, 2013).
\Benefits of Disclosure - ANS-Benefits of Disclosure
* Able to request reasonable accommodations
* Opportunity to have a job coach come to the worksite and communicate directly with employer
* Employee can involve an employment service provider, employee assistance program, or
other third party in the development of accommodations.
* Easier for employee to come to work during an exacerbation of symptoms
* May help with the recovery process
* Allows coworkers to offer personal support
* May empower another employee to disclose
\CASE STUDY 1
Karen Harris is a newly graduated PMHNP. She worked as a psychiatric nurse for 5 years
before going to graduate school. She is considering a job at the local community mental health
center.
,The director of the center has told her that her role would consist of seeing mainly adult clients
with serious, chronic, and persistent mental illness. On occasions when the psychiatrist is
"busy," Ms. Harris is told she may be expected to see a few children in addition to adults. The
director expects Ms. Harris to provide medication management to well-known clients and
occasionally to assist in diagnostic evaluations of new clients or clients in crisis. He also expects
that she will "from time to time" meet the emergent medical
needs of clients who have limited access to primary care providers, including the routine,
ongoing care of nonpsychiatric disorders such as diabetes, hypertension, and chronic pain. Ms.
Harri - ANS-ANSWERS TO CASE STUDY DISCUSSION QUESTIONS
Case Study 1
1. The key word here is "legally." Professional standards and scope of practice documents
suggest what is reasonable and prudent practice. Professional nursing organizations will
provide information on what is seen as acceptable educational preparation for practice.
However, the individual legislative regulations of each state
determine what constitutes legal practice for each individual PMHNP.
2. The Nurse Practice Act and related legislation of the state in which she practices will
delineate the legal boundaries of her practice.
3. Professional standards and scope-of-practice documents suggest what is reasonable and
prudent practice. The individual legislative regulations of each state determine what constitutes
legal practice for each individual PMHNP.
4. Professional nursing organizations provide information through a Scope and Standards
document about what is seen as an acceptable practice role for PMHNPs, but the PMHNP's
practice is ultimately guided by the individual state's Nurse Practice Act.
5. Any client, including a psychiatric client, has the right to refuse treatment. Ms. Harris is legally
and ethically bound to honor the client's rights.
6. Ms. Harris must meet the legal standard in the state where she practices to treat a client
against his or her wishes. This usually entails performing the legal task of committing a client
and in most states, ensuring that the following criteria are met:
ZZ The person has a diagnosed psychiatric disorder
ZZ The person is unaware or unwilling to accept the nature and severity of disorder
ZZ As a result of a mental disorder, a person is harmful to self or others
ZZ As a result of a mental disorder, a person cannot take care of his or her basic needs of food,
clothing, and shelter
7. A durable power of attorney
\CASE STUDY 2
A PMHNP working in a rural mental health clinic is asked by a women's clinic to evaluate Ms.
M., a 35-year-old female. Ms. M. insists she is not depressed, but that she has been feeling
understandably
distressed because she was fired from her job for excessive absenteeism related to "head,
neck, and back pain." Ms. M. has difficulty falling and staying asleep, wakes up feeling tearful,
and doesn't want to get out of bed. She has become socially isolative and spends hours sitting
in front of the television. She has been taking 50 mg of amitriptyline for the past 6 months. The
medication has been prescribed by a physician's assistant at a women's clinic. She was last
, seen at the women's clinic 4 months ago. After evaluating Ms. M., the PMHNP decides that she
meets criteria for major depression. He decides to continue the amitriptyline but
increases the dose.
1. How should the PMHNP explain his rationale fo - ANS-ANSWERS TO CASE STUDY
DISCUSSION QUESTIONS
Case Study 2
1. The PMHNP must discuss the treatment plan in the context of the client's psychiatric
symptoms. Without trying to convince the client that she has major depression, the PMHNP can
discuss how chronic pain may have led to the distress she is currently experiencing and that the
medication may address many of her distressing
symptoms. He will also need to address the potential side effects from this tricyclic
antidepressant, and the usual course of treatment in terms of dosing and timeline.
2. Yes, if the PMHNP is using the medication to target the client's depressive symptoms and if
he believes the benefit-to-risk ratio is reasonable in this instance, it is reasonable for the
PMHNP to continue the medication and adjust the dose. The PMHNP must do all the relevant
medical tests to prescribe this medication.
\Commitment - ANS-Commitment
* Process of forcing a person to receive involuntarily evaluation or treatment
* Process may differ from state to state
* Basic criteria include
** Person has a diagnosed psychiatric disorder,
** Person is harmful to self or others as a consequence of the disorder,
** Person is unaware or unwilling to accept the nature and severity of the disorder, and
** Treatment is likely to improve functioning.
* Involuntary admission
** Admission to a hospital or other treatment facility against the person's will
** Clients maintain all civil liberties except the ability to come and go as they please
** Amount of time clients can be kept against their wishes varies by state
* Voluntary admission
** Admission to a hospital or other treatment facility that a person desires or agrees to
** Client maintains all civil liberties
** Client consents to potential confinement within the structure of a hospital setting
\Competency - ANS-Competency
*A legal, not a medical concept
*A determination that a client can make reasonable judgments and decisions regarding
treatment and other health concerns
*A person is considered competent until a court rules the person to be incompetent.
