W#1 MH

POST # 2 NGOZY

Current Scope of Practice for the Role of Psychiatric Health Nurse Practitioners in Texas

According to the Texas Board of Nursing, the scope of practice includes activities that an individual health care provider performs in the delivery of patient care. Scope of practice reflects the types of patients for whom the advanced practice registered nurse (APRN) can care; what procedures/activities the advanced practice registered nurse can perform; and influences the ability of the advanced practice registered nurse to seek reimbursement for services provided. Determinants of the scope of practice include advanced practice education in a role and specialty, legal implications, or compliance with the Nursing Practice Act and Board Rules, and scope of practice statements as published by national professional specialty and advanced practice nursing organizations (Texas Board of Nursing, n.d.). 

In Texas, the Psychiatric Mental Nurse Practitioner (PMHNP) has limited practice authority. The current scope of limitations requires that the PMHNP must practice under the supervision of a physician within a 75-mile radius. Physicians can’t supervise more than four nurse practitioners at one time and must review at least 10% of the nurse practitioner’s patient charts randomly each month. Additionally, PMHNPs can only prescribe under a physician's supervision, cannot prescribe schedule two drugs such as Adderall, Norco, and all prescriptions written by the nurse practitioner must include the supervising physician's name, address, DEA number, and phone number. Nurse practitioners (NP) in Texas, are not allowed to sign death certificates or handicap permits (Texas Board of Nursing, n.d.). 

State Regulatory Environments on Advanced Psychiatric Nursing Practice as a Barrier to Mental Health Care

The aforementioned regulatory environments present a barrier to mental healthcare in a lot of ways. Although there has been significant progress across states to remove or diminish barriers to the exercise of the full scope of practice by advanced practice registered nurses (APRN), state regulations continue to unnecessarily restrict the APRN practice in Texas. In a desperate bid for Texas Nurse Practitioners to fight for full practice authority, a House Bill 1792 was proposed in 2019 that will allow for full practice authority; however, this proposal is still under deliberation (Texas Board of Nursing, 2014). The limited scope of practice regulation in Texas affects the size and distribution of the broader PMHNP workforce, access to care, health care costs and prices, and innovation in health care service delivery. Common themes include confusion about regulatory requirements and mixed experiences of mandated physician supervision (Phoenix & Chapman, 2020).

Texas law shapes the PMHNP scope of practice. The inability of the state of Texas to support PMHNP full practice autonomy can adversely impact patient care. APRNs in Texas do not have full practice authority under current state law. While doctors no longer have to be on-site to supervise, APRNs must have a collaborative agreement with a physician. This collaborative agreement requires that the supervising physician conduct chart reviews and hold monthly meetings with the APRN to discuss care plans and any issues with patient care. For example, the Texas State Nurse Practice Act mandates that a psychiatric nurse practitioner maintain a statutory collaborative agreement with a collaborating psychiatrist in order to provide comprehensive mental health services (Texas Board of Nursing, 2021). Although some third-party insurance companies authorize APRN-PMHNP on panels, a collaborative agreement must be established with a psychiatrist from each insurance panel. This becomes a critical issue when the collaborative psychiatrist decided to close his practice and abruptly discontinued the collaborative agreement. In order to prevent discontinuity in care, the APRN-PMHNP needed to establish a collaborative agreement with another psychiatrist and develop a practice agreement based on protocols established by the State of Texas. This time-consuming process will result in a disruption in treatment for several patients. The PMHNP managing these cases will report a major incident by high-risk patients that occurred as a result of this disruption in continuity of care. This case highlights the potential negative consequences and barriers to mental health care related to statutory collaborative agreements as well as the ability of a PMHNP to provide effective, safe, and consistent care. These barriers create a lack of motivation to enter the advanced practice field of nursing and provide a disincentive to PMHNP to set up practice in the community. 

Groups or Cultures Most Impacted by Texas Current Scope of Practice Regulations

I have noticed that Texas rural areas have experienced shortages of primary care providers. Nurse practitioners (NPs) are helping to reduce that shortage. However, limited NP scope of practice regulations has impacted the accessibility of care to rural communities (Ortiz et al., 2018). Research has shown that the costs of primary care have been rising and access to it may become limited because of a possible shortage of primary care physicians (Ortiz et al., 2018). Some state governments have addressed this issue by allowing Advanced Practice Registered Nurses (APRNs) serve the population without the supervision of physicians. Also, the aging population is feeling the adverse impact of the high cost of medical care due to multiple chronic problems and polypharmacy. NPs in primary care charge lower prices than physicians and provide a satisfactory quality of care, supported by existent literature (Woolbert & Ziegler, 2017). Thus, restrictive physician supervision requirements exacerbate provider shortages that could be mitigated via expanded APRN practice. Excessive supervision requirements increase health care costs and prices. For example, self-employed PMH-APRNs pay high rates monthly for MD supervision, which can be transferred to patients. PMH-APRNs in rural areas were significantly more likely to pay fees to maintain a supervising physician, adding to the practice expenses of APRNs serving vulnerable and underserved populations. In addition to the increase in health care costs related to payment of fees to a designated supervising physician, overly prescriptive supervision requirements represent opportunity costs. Time spent on activities such as mandated supervision meetings or routine review and even co-signing of NP charts by the supervising MD represent the time that could more productively be spent on patient care. High health care costs mean that the vulnerable, and poor populations in the society might not be able to afford the high cost of health care. In my opinion, mandated collaboration agreements are unnecessary to achieve the benefits of physician and APRN coordination of care. Worse still, the uninsured are much more likely than others to delay or forgo health care due to costs. 

References

Ortiz, J., Hofler, R., Bushy, A., Lin, Y. L., Khanijahani, A., & Bitney, A. (2018). Impact of Nurse Practitioner Practice Regulations on Rural Population Health Outcomes. Healthcare, 6(2), 65–67.

Phoenix, B. J., & Chapman, S. A. (2020). Effect of state regulatory environments on advanced psychiatric nursing practice. Archives of psychiatric nursing, 34(5), 370–376.

Texas Board of Nursing. (n.d.). Practice-APRN scope of practice. Retrieved May 3, 2021, from https://www. bon.texas.gov/practice_scope_of_practice_aprn.asp

Texas Board of Nursing. (2014). Texas Board of Nursing. Texas Nursing Practice Act. Retrieved May 3, 2021, from  http://www.bne.state.tx.US

Texas Board of Nursing. (2021). Current Rules and Regulations Relating to Nurse Education, Licensure, and Practice. Retrieved May 3, 2021, from  https://www.bon.texas.gov/laws_and rules_rules_and_regulations.asp

Woolbert, L., & Ziegler, B. (2017). A guide for advanced practice registered nurse practice in Texas (4th ed.). Coalition for Nurses in Advanced Practice and Texas Nurse Practitioners.