Role of the PMHNP

Added: 2026-05-15

[00:00:01]hello this is Dr Gardner from nickoll State University and I am going to be lecturing on the role of the psychiatric mental health nurse practitioner regulations and scope of practice so why do we review the role of the psychiatric mental health nurse practitioner the regulations in the scope well that's the role that you're going to do correct also the domain of the professional role in policymaking comprises about 30% of the exam content for andcc all advanced practice nurses should be familiar with rules and regulations that pertain to their job so the objectives for this lecture we'll identify different types of leadership styles we will EXP explain the Therapeutic Alliance describe health promotion describe quality improvement processes explain the role of the psychiatric mental health nurse practitioner demonstrate understanding of advanced practice laws and ethical procedures so we'll start off with the federal government we will do a quick review of our government and why is it important because they govern what we do so the primary role of the Federal Government concerning healthc care delivery is interpreted under the Commerce Clause of the US Constitution with an emphasis on regulating interstate trade there are three branches of federal government described in the constitution of the US and each branch has a separate but equal power there is the executive branch that is the president right the president signs bills passed by the Legislative Branch into law and deals with National Security issues the legislative branch that's the House of Representatives um they debate and introduce bills to be signed by the executive branch they control all federal money they supervise all agencies of the federal government they also oversee the centers for Medicare and Medicaid services which is also CMS CMS is the administrative arm of the federal government that directly influences every aspect of healthc care delivery in the US so you need to understand that that is why it's important the CMS determines reimbursement rates based on profession including the international classification of diseases which is the icd10 and the current procedural terminology which is the CPT codes and that's covered by which profession so they determine how it's classed and how it's coded and how we're paid so accreditation it's voluntary however you won't get reimbursed if you're not accredited so um it's tied to um Medicare and it's a federal entit entitlement program that's Medicare is a federal enti entitlement program for those over 65 and where the individual or spouse has worked at least 10 years or they're legally disabled or they have endstage renal disease and there's different part so Medicare part A is hospitals and inpatient stays that are me medically necessary Medicare Part B is outpatient services so that's clinics anything that's going on out there um Medicare Part c those are advantage plans um and that's private insurance that's managed by part A and Part B so it's Medicare Advantage plans there is Medicare Part D which is prescription drug benefits a person must be enrolled in a supplemental plan and only formulary medications are covered so you can't just have Medicare Part D they will have another part of the Medicare as well so they have to be in one of those supplemental plans to have part D and only medicines on the formulary are covered and most of the newer medications are not usually covered by Medicare so you really have to know which medications those patients will be covered for um because if the medication costs too much that patient is not going to take it so be very conscious of when you're prescribing for a Medicare patient Medicaid same thing they have a formulary which they're very strict about so you have to learn the Medicaid formulary which is not always the same as the Medicare so there's Medicaid there's Medicare Medicade formularies are very strict they follow a tier so you have to prescribe certain medications before you can get to a different medication um they usually need prior authorizations for their medications and the icd1 code most often than not needs to be on the prescription so Medicaid is a pair of Last Resort for lowincome meeting um poverty level criteria it's one of the largest payers of Mental Health Service is Medicaid and finally we have chip which is children's health insurance plan and Chip although it's the children's health insurance plan it covers uninsured children and pregnant women continuing on um Federal restrictions on advanced practice nurses are due to the administrative laws described in the CMS regulations only Congress can pass a bill to amend the language of the CMS regulations pending the signature of the president of the United States so you have to understand how these laws work how your reimbursement is especially um because a lot of it is based on the CMS so when one thing you are probably familiar with is the drug enforcement agency or the DEA the DEA regulates control substances so if it's a scheduled medication it is regulated by the DEA and which is well I we will have DEA numbers so you have to apply after you have a certain amount of hours you can apply for a DEA license and that is the only way that you can prescribe control substances in Louisiana you also need a CDS which is a control dangerous substance license but providers who are prescribing controlled substances must have a DEA number and the Federal Bureau of Investigations or the FBI they investigate crimes across state lines that have anything to do with the DEA next we have the Food and Drug Administration the FDA approves and regulates medications and medical devices so you know there's always studies new medications have to go through the FDA for approval before they are on the market we have the Centers for Disease Control and prevention the CD the CDC in the Department of Health and Human Services which is the DHHS tracks Public Health Trends Aggregates data and publishes mandates for public health and safety so this is just a review for you guys you should all know this and we have the health insurance portability and accountability Act of 1996 which is Hippa Hippa is a legislative privacy and security laws to protect personal health information um identifiers from disclosure without a patient expressed consent um it guarantees patients four fundamental rights that they have to be aware of hipper protection and confidentiality so that patient should be signing something that there is a protection confidentiality in place they must have access to their medical records there is a cares act also now that patients should have immediate access to their records now Psychotherapy notes are not a part of the record however with most of the electronic health records all of your note it's not really separated from Psychotherapy and your regular note so the patient will get that note they have a right to that note if it is a Psychotherapy note um those are are not counted in that because sometimes there's information that can harm the patient that they don't need to read so those are not a part of the record that has to go to the patient anything like prescriptions when the session starts and ends um any kind of frequency um of treatment their test results their summaries their prognosis any consultation reports that's all considered a part of the record and the patient has a right to their record the patient can also request an amendment to their record if they object to the content now they can request it if it is something that is truthfully documented that doesn't have to be changed so a patient is not going to dictate what it is but if there's something erroneous in that record that they object to um they can request to have that changed or amended and then there's cobra Cobra um is the Consolidated Omnibus budget reconciliation act Cobra covers people who are going to need insurance um if they're no longer working at their job it allows an individual to carry their health insurance from their previous employer for anywhere from 18 to 36 months if they pay for it and Cobra is very very expensive and finally we have the judicial brand branch and the judicial branch is the federal court system so when we talk about advanced practice laws and governing bodies we'll talk about individual states because individual states create laws and govern professional practice and they Grant lenser Li lure the nurse Practice Act defines the work of nurses and advanced practice the nurse Practice Act dictates the state's duty to protect the public from unsafe nursing practice it delates practice privileges lure process and explicit restrictions and educational requirements for licensers basic competencies lure is the process by which an agency of state government grants permission to individuals accountable for the practice of profession to engage in the practice of that profession so Louisiana state board grants licenses to lpn's RNs aprns so that your license is obtained on a state level credentialing that's the process to verify the minimum levels of professional competence to ensure Public Safety so when you are hired on at a practice or a facility they will do credentialing and what they're is doing is they're verifying that you have the minimum levels of professional comp competency to ensure Public Safety so anywhere you work will credential you they are obligated to credential you certification that's a credential that allows for title protection so once you're certified bycc now actual actually a is also offering a certification exam but you get a credential to work as a psychiatric mental health nurse practitioner once you pass the certification exam so they're certifying bodies and so that credential allows for title protection and it determines the scope of practice it's granted by a professional organization and it certifies that an individual meets the minimum requirements of professional practice so in order to pass your certification exam you're being tested on the minimum level that certification communicates Mastery of knowledge and it provides title protection so who can be called an NP so if you don't have a certification by a certification body you cannot use that credential it grants legal Authority and establishes mandates for nurse practitioner practice so talking about States states except ction to confidentiality varies from state to state so what is done in Louisiana may not be done in Texas or may not be done in Florida and it is usually enacted as a result of case law decided by the J judicial system so um if like intent somebody has an intent to harm themselves um the duty to warn so the duty to warn of imminent danger so if you are a provider and one of your patients is saying oh I am so mad I have been dating this woman I found out she's cheating me cheating on me I'm going to kill her I'm going to kill her dead sounds like they from down the bite okay sorry I'm from down the body so I hope nobody's offended by that joke anyway um there is something called the teror off principle of 1976 and that is a duty to warn of Po potential victims of imminent danger so this patient is in here telling you he is going to go and kill her if you have to warn her you have to warn her and of course you let the authorities know he is out to kill her if you don't if you think that protecting this patient's confidentiality supersedes warning that victim it does not um also we report child and elder abuse as well we have a duty to report any child abuse any elder abuse it may be difficult you feel like you're betraying somebody but your duty is to report any abuse okay we're going to go over some terms um the first is informed consent informed consent is is respecting the patient's right to autonomy and that's a communication between the provider and the patient and that clearly explains the risks and benefits of particular treatment the condition they're being treated for the risks and benefits of refusing that proposed treatment in any alternatives to the proposed treatment so you have to gather and inform consent the patient has to know what they're signing up for and no assurances should be made for a particular outcome of any treatment informed consent can be obtained from emancipated miners next we have capacity capacity is a clinical decision based on a psyche vow to determine the patient's ability or power to do experience or understand something so you may actually have to do a complete physical with labs to determine that so what some questions you may ask is um what's your understanding of the condition and what are the options for your situation what is your understanding of the benefits or treatment and odds of success so that's how you can determine if they understand um what is your understanding of what will happen if nothing is done so you understand their capacity confidency that is a legal designation regarding a person's AB ability to make reasonable decisions regarding their own well-being all persons of legal age are presumed to be competent unless a court declares the individual incompetent so we'll talk about involuntary commitment criteria that varies from state to state so depends on what state you're going to work in as to what that criteria is but if a patient has to be involuntarily committed because they are a danger to themselves or someone else they still retain all of their civil civil liberties except for the ability to come and go as they please they don't have that and some of the general criteria include the person must have a diagnosed psychiatric disorder they must possess harm to themselves or someone else they're unaware or unwilling to accept the nature and severity of the disorder so it could possibly be a schizophrenic patient unmedicated um that cannot um take care of themselves or understand the severity of that disorder then they may need to be involuntary committed to get them stable um also treatment is likely to improve their functioning so again that schizophrenic patient um who is having a crisis may need to be committed to get them stabilized so there's different um professional organizations there's the American Nurses Association um American Academy of nurse practitioners there's the American Psychiatric um Nurses Association so professional or there's so many more this is just a few of them but professional organizations are important if you don't already belong to one um consider joining and as a student usually you can um join for very very deep discounts so we'll talk about scope of practice in scope of practice says who may do what when where and how it's governed by the terms of the state's professional license or the nurse Practice Act the scope of practice is limited to each State's nurse practice act so in Louisiana we follow Louisiana's nurse Practice Act it says what nurses are able to provide What nursing care and under what circumstances standards of practice um it's an official reference explicitly stating the rights and privileges regarding the type of practice it defines the NP roles and actions and it identifies competencies assumed among members of the profession it also um it reflects expectations of care and can be used to legally describe work of the profession and there are certain standards of care that I will post a link that you can go and look at the different standards of care for mental health there is also a book however you have to purchase that book I will post a link to the book in the course but you do not have to purchase it it is good to have especially when you are learning and don't know so it is a good resource to have but you are not obligated to buy it okay so let's talk about the role of the nurse practitioner so the one of the core competencies is managing and negotiating healthc care Delivery Systems so you negotiate legislative changes consider financial implications related to healthcare delivery utilize business principles to promote Justice um in be an advocate be we have to have our voices heard but if we're not out there involved at the capital trying to get changes changes will not happen so there are so many other states with full practice Authority Louisiana is not one of those States we still have a collaborative practice agreement so you cannot work independent of a physician you can have a practice but you need a collaborating um a collaborative practice agreement to do that whereas if you worked in Washington you do not if you work in Oregon you do not there's several states that you can work on your own with full practice Authority that's because legislation changes things in different states so if you're involved get your voice heard go to the Capital go to when the nurse practitioners are at the capital let those speakers hear your concerns we monitor quality indicate indicators so we incorporate evidence-based practice principles into our daily practice that is how we practice evidence-based medicine cut and dry we provide cultural sensitive care so we increase personal cultural sensitivity and awareness when assessing patients perceptions of illness and hell and we consider the cultural interpretations of our the various roles in healthc care delivery and a part of our professional role is advocacy we have to stand up for our patients rights and Empower them to self- advocacy so we Empower our patients to advocate for themselves we are empowered to reduce the stigma associated with mental illness help patients receive available resources participate in professional organizations and we work collaborative collaboratively across and within organizations some of the different places that PSY iatric mental health nurses can work is Private Practice hospitals schools universities jails act teams there's so many different places that we can work but our core competencies remain the same okay next we will talk about different types of leadership styles and why do we talk about leadership styles because nurses should be leaders and engage with Health Professions to transform and redesign Healthcare that is also one of your roles so what type of leader are you are you a transformational leader transformational leadership is marked by a charismatic ability to communicate vision and secure buying from stakeholders situational leadership that's a style marked by flexibility and adaptability to the context of the situation and an ability to engage at various levels with key stakeholders and address their concerns then there's the authoritarian leadership and that style is motivated by independent self-directed individuals who prefer to give specific directions and exert control over a situation with little to no input from anybody else in charge so what you say goes I don't want to hear anything else this is how it's going to be and that's it that is an authoritarian leadership a Democratic Leadership is emphasizing the team process and it's valuing input from stakeholders um and decisions are made by a consensus so it's more of a you're listening to what everyone has to say and then a decision is made it's not just the decision of one person there is a Le a fair leadership and that's marked by indecision and ambiguity so it's suited to figurehead individuals who have very experienced autonomous and self-directed subordinates so pretty much they trust those underneath them to make all the decisions they just kind of sit at the top and let it happen and then there's the servient leadership that's a style marked by the follow me rather than a forward March in that approach the leader Works alongside the subordinates adopting to fill in the gaps and they may um inadvertently enable poor performers when they do that nurse practitioners are educated to lead interdisciplinary teams at as full Partners in the care nurse practitioners nurse practitioners design Implement evaluate and Advocate to redesign Health Care Systems and engage in evidencebased clinical practice okay we're back to the core competencies health promotion and disease disease maintenance disease prevention education therapeutic interventions comprehensive physical assessment and psychiatric evaluation and that entails the mental status exam diagnostic tests distinguishing various uh variations of normal from abnormal the physical exam by the psychiatric mental health nurse practitioner with neurological emphasis the family system evaluation and prevention screenings Guided by clinical guidelines so these are some of the core competencies of the psychiatric mental health practitioner so when we talk about the comprehensive physical assessment in psych eval psych nurse practitioners should rule out underlying medical conditions and screen for non psychiatric disorders you're going to evaluate physiologic reserve and functional ability compile differential diagnosis and identify a primary psychiatric Disorder so you will always identify the differentials and have a primary psychiatric disorder you will utilize the dsm5 TR and icd10 codes for the treatment and planning and coordination of care so that DSM 5tr get used to it you will use it in this course you will use it in your next course you will use it in the course after that and you will continue to use that after you graduate so mental health promotion and education that is we are teaching coping strategies you are distinguishing a barrier of no mental illness with a normal variation helping identify feelings and behaviors and you help patients identify Community Resources from mental health we provide psycho education psycho pharmacology education of patients um we monitor for adverse effects of our psychopharmacology we also provide oversight and authorizing services and benefits we also want to promote coste effective quality outcomes and be involved in patient centered medical home homes when needed okay let's move on to ethics so we talk about ethical principles which is governing decision making ethical principles govern decision making so there's different um types of governing which there is autonomy and that's the right self-governed free from any external control or influence of course the patient must be involved and they do have the right to refuse treatment unless they're incompetent and they also have the right to be treated with the least restrictive Manner and in the least restrictive setting benian is doing good and promoting wellbeing nonm fence is doing no harm veracity is Conformity to facts truthfulness and accuracy Justice is the quality of being Equitable and reasonable and of course respect is regard for the feelings and wishes okay and the rights and traditions of others so respect is the regard for the feelings wishes rights and traditions of others so in in there's some ethical decision-making dilemmas a dilemma is a situation in which two or more justifiable Alternatives have both similar risk and benefit that causes a dilemma a deontological theory is the action judged as good or bad on its merits regardless of its consequences patients have the right to know what's happening during their treatment so remember patients have the right to to know what's happening during their treatment you do not hold that from them and the te telogical theory is the goodness and Badness of an action is based on the foreseeable consequences so as a result of disclosure the patient may have legal resource recourse for financial restitution individuals may suffer harassment or discrimination um they may request reasonable accommodations um opportunity for personal support from peers and then there's virtue ethics virtue ethics is the actions are based on moral or ethical principles providers have an ethical duty to disclose errors accidents injuries and positive test results to their patients so if you make an error you have a duty to disclose that era so that is virtue ethics so we've already discussed dilemma we discuss the deontological theory and we discussed the telogical theory cultural competence dictates people should be treated as Unique Individuals by considering their social context when providing care and we want to have cultural awareness that dictates using the knowledge of the individual's cultural experience to inform the clinician's interpretation of the signs symptoms and perceptions while applying the ethical principle of of respect so what is culture culture is the beliefs values behaviors and characteristics among members of any group ethnicity is self-identified descriptor of like a race a tribe A nation or a community culture bound syndromes is transient nonpathological behaviors associated with culture it's essential for clinicians to be mindful of this phenomenon to avoid inaccurately labeling this as a psychiatric Disorder so if a patient says I need to consult with my great grandma before we do anything I I can't agree to this treatment pray this treatment plan unless I consult with my great grandma and you say okay after you talk to your great grandma come back or you know do we need to call Great Grandma and she's like oh no she's dead that does not mean that you cannot equate that to a psychiatric illness of your patient that is a cultural norm for that patient environmental determinance of health is the the safety of the immediate surroundings their climate their air W their water quality um stability of Financial Resources socialization crime exposure Transportation climate control then we have cultural Health determinant so families pass along Norms beliefs and values related to essential functions of da daily living like food shelter safety belonging and education and we have to consider special populations so that would be like the homeless population um sexual minorities victims of domestic violence who are fleeing their home to live somewhere else so there's so many different considerations when we're treating patients um in all of this Encompass the cultural competence that we must display so we'll end with health promotion health promotion involves having familiar familiarity with the leading causes of death so you as a provider should know what the leading causes of death are at the present time immunization schedules um preventive strategies routine screenings based on age and stages like this this is something that you will do even as a psychiatric mental health nurse practitioner and this allows you to provide anticipatory guidance to your patients so this should be a review for everybody um um when we talk about specif specificity that is the degree of confidence in a test for a particular condition or trait that looks for a true negative and that's to rule something out right um and it's a very specific test to rule out a disease with a high degree of confidence so spe specificity is to rule out whereas sensitivity is looking for the true positive and that's going to rule in a dise a disease so a degree of confidence in a test to detect the presence of a true positive is sensitivity primary secondary and tertiary um prevention we'll just review that briefly this is a review primary is healthy people are provided the advice like balanced diet wear your seat belt exercising using helmets maybe workplace safety measures um talking about not drinking and driving some general measures for mental health like having Hobbies friendships support systems of purpose that's all primary and prevention is used to reduce morbidity and mortality right due to different disease conditions secondary prevention is looking for disease in a group that's at risk so sensitivity right um by checking their blood pressures doing mental health screenings like the phq9 or the mental status exam um screening for sexually transmitted infections using long acting injectables to prevent recurrence of psychosis um patients taking medications like methadone or nxone that's all secondary prevention and tertiary prevention that's reducing disease progression in someone who is diagnosed often after an acute treatment and stabilization so like drug rehab alcohol rehab therapy psycho education support groups that's all tertiary okay we will end this with anticipatory guidance anticipatory guidance is a tailored prevention framework to reduce morbidity IM mortality it assumes information provided in a timely manner will reduce morbidity and mortality mortality along with lifespan and it all of this has to be done in a um the need for information is determined in a systematic manner because you need to know what is important for your patient so providing information in a timely manner should reduce morbidity IM mortality sites like Bright Futures that's web-based guidelines for anticipatory guidance for children and that's because every child deserves a healthy and optimal relationship with a healthcare provider so anticipatory guidance we're going over this because it is part of your psychiatric eval for this course anticipatory guidance I do believe is worth about 20 points and remember 20 points is not three sentences um eliciting information um that's getting information from Key individual uals regarding the unique needs of the patient based on age disease developmental Milestones um medication adherence so you could do like car seat safety water safety stranger danger red flags and then there's Health specific guidance which is assisting individuals to meet the health care challenges across the lifespan like the anticipated decline in death and grieving um anticipate anticipated disease progression such as like Alzheimer's disease or psychotic disorders exploring the risk of domestic violence um Survivor coping after divorce or death so those are all specific so when you're doing your anticipatory guidance it should be specific to your patient okay and that is it for this lecture please let me know if you have any questions