History and Scope of Practice

APPNs have a 20-year history of prescribing medications in one form or another in the United States. The early days of physicians signing pads of prescriptions for nurses, who then assessed and prescribed for the patient, are gone forever. The rationale for that behavior was that nurse prescribing was a delegated function of the medical profession and that the nurse prescriber was carrying out a medical function for the physician. State laws governing scope of practice have changed to ensure patient safety and to clarify where responsibility lies for prescriptions that are written (Kaas & Markley, 1998; Phillips, 2006). Bailey (1999) provides an excellent history of prescriptive authority in the United States and the evolution of nurse prescribers in terms of scope of practice laws, educational preparation for the role, and the politics involved in the process.

APPNs’ expanded prescribing authority has increased our treatment repertoire, marketability, and collaborative status with colleagues as we have moved more deeply into the prescribing role. With this role comes more responsibility and more liability (Grimaldi & Cousins, 1998). The act of prescribing and its consequences are the responsibility of the APPN, who has been authorized to prescribe by virtue of education, national board certification, and by meeting any other requirements of the scope of practice law in the state where s/he is licensed.

Prescribing responsibility may be borne in part by a physician or another advanced practice nurse prescriber if the law is written in such a way that one of these other prescribers supervises the APPN who is prescribing. This does not excuse the prescribing APPN from responsibility, because responsibility always remains with the prescriber. For example, one newly board-certified APPN accepted the advice of his physician supervisor and employer, who told him that the fact that he was working in an employed status in his practice excused him from taking the steps necessary to obtain a nurse prescribing license in his state. The APPN came to the attention of the examining board in nursing and was held accountable for practicing without a license. There were severe consequences for him and his family professionally, financially, and personally.

Thirteen states and the District of Columbia allow some categories of APPNs to prescribe without any physician involvement, and 37 states allow prescribing with physician involvement at some level (Phillips, 2006). Some of the 37 states specify the board certification required for prescribing, and some specify the Boards that can certify them (Phillips, 2006). For example, some states have allowed only board-certified clinical nurse specialists in psychiatric mental health nursing to prescribe, and they specify that only the American Nurses Credentialing Center is an acceptable body to confer certification. The first and most important function of a nurse prescriber is to understand and strictly follow the requirements of her or his state scope of practice law and any regulations that have been promulgated to explain it. Physician supervision can be defined in different ways in different state statutes; some states use the term collaboration with physicians rather than supervision. These terms may then be defined broadly or narrowly in the statutes of different states. The supervisory or collaborative requirements and their variations have very little to do with APPN competence, which is determined by academic preparation and board certification, and a great deal to do with politics. In some states, a collaborative agreement is required by statute and developed with the terms of this collaboration delineated, complying first with the practice statute and then with additional terms as agreed by the APPN prescriber and the physician or psychiatrist collaborator. The APPN prescriber and the physician sign the agreement. Sample agreements that comply with a particular state’s scope of practice law are included in the appendixes. Appendix II-2 (p. 274) is written as broadly as possible, whereas Appendix II-3 (p. 275) has more specificity. The broader agreement satisfies the requirements of the law. Appendix II-3 (p. 275) was developed to satisfy the wishes of some collaborating physicians for further specificity.

Liability insurance must be carried by every nurse prescriber. The individual and aggregate dollar amounts that must be carried are set in state law by some states. Some APPNs carry malpractice insurance only through the agency of employment; others individually insure. Some malpractice insurers and practitioners argue in favor of maintaining private malpractice insurance as there may be limitations and stipulations on employer coverage. For example, an APPN may not be covered in the case of a lawsuit brought sometime after s/he terminated employment with the agency or hospital if there is a clause in the contract terminating coverage at the point of employment termination. Individual malpractice insurance coverage provides for portability and for coverage that can be fully known and fully evaluated by the APPN. Agency coverage may be attractive to the APPN because it is much less costly in the short run, but it ascribes a great deal of power to the employer and may leave the APPN at risk.

Concerns about liability have made some APPNs reluctant to practice independently. Concern is well founded but need not be a deterrent to independent practice. The APPN is legally responsible for the clinical decisions made in practice, and the importance of understanding and practicing within the law governing APPN practice in the state and within the scope of practice as defined by the professional organization and certifying bodies cannot be underestimated. This is true whether the APPN is practicing in an independent setting or in another practice arrangement, and it is true in states that allow APPNs to practice without any mandatory collaborative or supervisory requirements and those that have these requirements. APPNs who understand that they are fully accountable for all clinical action and inaction, who practice within their scope of practice and obey the practice law in their states, who seek consultation from appropriate expert peers or refer the patient for a consultation when necessary, and who maintain a strong therapeutic alliance with their patients create an atmosphere of trust and collaboration that helps to deter the possibility of litigation. It is helpful in the clinical decision-making process to think about what a community of peers would say about a planned intervention, and if there is discomfort of any kind, consultation should occur before action is instituted. An important protection for the APPN who does become involved in questions or accusations about his/her practice is the thoroughness and quality of documentation in the record, including consultation discussions.

APPNs who schedule regular clinical supervision are adding depth and new perspective to practice, giving patients the benefit of “fresh eyes” on the diagnosis and treatment plan and demonstrate a willingness to allow review of their work by peers or other experts in the field. This is helpful and protective for all involved in the treatment, and it is recommended that this be a routine arrangement in any practice setting. It may be even more valuable in the private practice setting, where the APPN is often working in an isolated environment. These arrangements may be mandatory or voluntary, depending on the state law. Business arrangements between the APPN and the clinical supervisor must be carefully established because it can be costly in terms of the frequency of the meetings, the fees that are charged, and the time and costs of travel and for the supervisory session. The final business contract must be fair and equitable to prevent negative feelings from affecting the work in supervision. It may be necessary to interview more than one potential supervisor before a satisfactory arrangement can be established. An alternative may be to create a peer supervision group in which members agree to regular meetings in which each member brings patient treatment issues before a community of peers for review and consideration. It is always necessary in states that have mandatory supervision or collaboration to know what the qualifications of the supervisor must be.

APPN prescribers practice in too many settings to enumerate in this chapter. Research supports that APPN psychotherapeutic and pharmacotherapeutic approaches produce direct health benefits (Jones et al., 2006). Practice models for prescribing have emerged in different settings, often from the practice needs of the setting and from the needs of the patients being treated and cared for. Some settings allow for the most liberal interpretation of its state’s prescribing law, and in states where the prescribing law itself is liberal, the APPN may be allowed to prescribe to the full extent of her or his professional scope of practice. Other practice settings are highly restrictive, and APPNs are more limited in prescribing practices than even a restrictive state law would demand. The APPN who practices in a fully independent setting without practice requirements and restrictions imposed by an institution or agency may practice in accordance with the scope and standards of psychiatric mental health nursing practice as defined by the appropriate professional nursing organizations (ANA, 1994), but always within the parameters set out in the nursing scope of practice statute in his/her state (Phillips, 2006).

Competencies and Principles of Prescribing

A Statement on Psychiatric-Mental Clinical Nursing Practice and Standards of Psychiatric-Mental Health Clinical Nursing Practice (ANA, 1994) delineates the knowledge base required for APPN prescribing. After reviewing this document, Bailey (1999), in her seminal article on APPN prescribing, thoroughly described the components of the neuropsychosocial and psychopharmacologic assessments that are essential in establishing a psychiatric diagnosis and determining appropriate pharmacologic treatments. These include integrated knowledge of the biologic, behavioral, and social and neurosciences; knowledge of central nervous system structures and function; and theoretical understanding of mental illnesses based on biologic knowledge. She states that the APPN must also have knowledge of sleep stages, circadian rhythms, and neuroimaging techniques and the paper and pencil tests available to assess and monitor mental illness and treatment. Twelve areas are identified that require APPN expertise in conducting an adequate neuropsychosocial and psychopharmacologic assessment (Bailey, 1999) (Box 9-1). Specific components of each of these areas are discussed in the comprehensive assessment described in Chapter 4.

Another area that bears exploration in a psychopharmacologic assessment is that of the patient, family, and significant others’ feelings and values about mental illness and the use of medication to treat it. Many people feel ambivalent about emotional problems being conceptualized and labeled as illness, and prescribing medications to treat them reinforces the idea that these symptoms are manifestations of medical illness. There is also a belief held by some people that medications can make symptoms worse, and this may raise fear at the idea of using medications. Careful consideration of the concerns of patients and important others presents an opportunity for education and for reducing resistance to medication later.

The APPN must know as much as can be known about the patient, but that is only one aspect of the expertise that is needed. The APPN must also be firmly grounded in knowledge about the medications. This includes knowing similarities and differences among agents of the same and different classes, the mechanisms of action, side effects, adverse effects, interaction effects, and other variables essential in the risk-benefit assessment that must precede the prescribing of any medication (Bailey, 1999). APPNs need depth of knowledge and skill in performing all these functions to identify the findings that provide the basis for diagnosis and treatment planning. After initial treatment planning and treatments are in place, the APPN continues until termination of treatment to monitor target symptoms, medication effects, and level of function.

Short- and long-term maintenance care, or follow-up, requires its own set of skills and may be at least as challenging as the initial assessment and treatment plan. Essential to follow-up care is the APPN’s ability to interpret data from ongoing drug monitoring, including objective assessment of target symptoms, laboratory values, patient and family reports of drug response and level of function, and rating scales (Bailey, 1999). Competency in identifying indicators for medication modifications or tapering and clinical expertise to choose alternative medications strategically are needed (Bailey, 1999). The APPN prescriber understands potential withdrawal consequences of discontinuing medications and is able to distinguish among recurrence of illness, drug rebound effects, environmental effects, and personality characteristics when the patient reports changes or when medications are tapered. Patient education on all aspects of the illness and treatment, rehabilitation measures, and other health promoting interventions are ongoing components of long-term care (Bailey, 1999). All of these require ongoing assessment and intervention, because it is almost inevitable that there will be changes in mental state, functioning level, and interpersonal and environmental stressors over time. Bailey (1999) provides 11 basic principles for psychopharmacology practice (Box 9-2).

Off-label prescribing and distribution of samples are two situations that the APPN should understand require special consideration. Off-label prescribing refers to the prescribing of certain drugs that are not approved by the U.S. Food and Drug Administration (FDA) for psychiatric use at all or are approved for a particular psychiatric treatment but are prescribed for a different purpose. For example, certain anticonvulsants sometimes are used as mood stabilizers, but they were never approved as mood stabilizers. Another example is that of an atypical antipsychotic used for anger management, impulsivity, or certain instances of insomnia. The APPN must have a clear rationale for prescribing such drugs and document in the record why it is the drug of choice. The patient must be informed of the drug’s off-label status and agree to a trial of the medication. Informed consent must be documented in the record.

Samples of brand-name medications are distributed to APPNs by pharmaceutical representatives, and each APPN must decide about the appropriateness and timing of providing samples to patients. One model is to provide the “starter pack” of the medication or its equivalent to see if the patient can tolerate the medication and thereby save the patient the co-payment if the drug is not tolerated. After that trial has been successfully completed, patients receive a prescription for ongoing use. Patients sometimes may be given samples of medication change for the same purpose, and some patients may need help with samples when co-payments are excessive or when they have no insurance. Providing starter medication is acceptable but should always be discussed in the context of the therapeutic relationship and should not be a permanent solution in most cases. Some prescribers work with the patient and drug company to ensure an ongoing supply of medication when the patient is financially unable to afford it. Casual dispensing of samples can be driven by relationship issues, such as the prescriber’s feelings for the patient, and the patient may attribute meanings to this act that are not intended. APPNs who develop a structured plan for dispensing samples may avoid misunderstandings and expectations that cannot be fulfilled.

Therapeutic Relationship

Bailey has called the therapeutic alliance “arguably the most important determinant of adherence to pharmacologic treatment” (1999, p. 309) and states that adherence to the pharmacologic regimen is vital to success of treatment in terms of feelings of well-being and level of functioning, regardless of the diagnosis. Relationship factors are first among the many aspects of the art and techniques of prescribing that are discussed in this chapter. The emphasis on what to prescribe in contemporary practice has overshadowed focusing on how to prescribe (Mintz, 2005). Many of the components of effective prescribing beyond the neurobiologic sciences and assessment skills belong in the realm of the therapeutic relationship. Prescribing skill may affect all aspects of the treatment. Compliance may be related in part to the therapist’s skill in presenting herself and the recommendations to the patient.

Nursing is a therapeutic interpersonal process, an educative instrument, and a maturing force that moves personality toward creative constructive, productive personal and community living (Peplau, 1952). These words have guided psychiatric nursing practice for many years and apply to prescribing practice within psychiatric nursing. The challenge for the APPN in any prescribing practice is to maintain a sense of professional self as a therapeutic interpersonal educative instrument while performing what is an essentially technical treatment task that is heavily dependent on theories in the neurobiologic sciences. The high value placed on medication treatment by medical insurers, pharmaceutical companies, and much of the consuming public, together with the rewards for being a provider who has expertise in biologic psychiatry and has the legal authority to prescribe, can powerfully influence APPN practice patterns and content. There is pressure from multiple directions to assess quickly, prescribe immediately, and keep meetings with patients short and infrequent.

Many APPNs believe that the biologic component of pharmacotherapy needs to be balanced with a firm grounding in the essence of nursing, which may also be seen as the essence of prescribing: psychological understanding of human behavior, interpersonally focused assessment, therapeutic relational skills, and therapeutic use of self. Both the biologic and psychological expertise contribute and are essential to knowing what and how to prescribe. The psychotherapeutic interpersonal processes are the core of psychiatric advanced practice nursing and essential to prescribing successfully. The therapeutic relationship is essential to a positive medication treatment experience for the patient, and it is essential to successful outcomes in medication treatment.

Integrated Treatment

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