NINE YEARS ago, this column discussed the increasing frequency that advanced practice registered nurses (APRNs), primarily nurse practitioners (NPs), were being faced with providing behavioral health services to patients in their practice when the NPs' education and certification did not focus on treating psychiatric and mental health problems.1 At that time, the nursing profession had been heavily negotiating for 4 years the tenets of what became the 2008 Consensus Document for APRN Regulation: Licensure, accreditation, certification, and education.2 It seemed that we were moving toward agreement that we could not solve the problem of insufficient behavioral health providers at the expense of exceeding scope of practice (SOP) because significant patient safety and liability issues were created when APRNs practiced outside of their recognized SOP.

Still, if APRNs did not provide care, patients' needs would not be met. Formal mental health services, especially in rural and remote areas, were sporadically offered, and there was limited access to care for behavioral health conditions. While adult and family NP curricula covered some aspects of behavioral health, it was not intended to prepare those NPs to provide complex psychiatric services at the same level as the psychiatric mental health nurse practitioner (PMHNP).

Today, the problem of resource maldistribution and patients needing care remains basically unchanged. Increasing numbers of patients require mental health services in all settings. Many of these patients are being cared for in family practice settings by APRNs who are not PMHNPs. Often, this care must go beyond medication management and treatment of more simple behavioral issues that resolve in shorter time durations. Family nurse practitioners are being forced to practice in a very similar manner to PMHNPs, simply because those necessary resources do not exist in their communities.

The outcome of the 2008 Consensus Document distinguished the populations that differently prepared APRNs would care for, but full implementation of the Consensus Document in every state did not meet the 2015 target. While we have to commend formal nursing education for basically doing its part to fulfill the Consensus Document requirements, full practice authority and a better distribution of APRN resources have been more difficult to achieve. Today, state legislatures and boards of nursing, along with other stakeholder groups, continue the slow progress toward full practice authority for APRNs.

For APRNs, SOP is a legal term that defines what practitioners can and cannot do within the parameters of their education, training, experience, and certification. Statute, rules, policy statements, and other regulations provide clarity to the SOP-or do they? In the United States, we are fortunate to have, for the most part, a uniform SOP for registered nurses so that when nurses moves from state to state, they can expect to know that the job functions and roles of a registered nurse in their new states will be the same or very similar to the job they held in their former states. This situation has promoted the success of the Registered Nurse License Compact. Much of this uniformity ceases in the world of the APRN who moves from one state to another. Diverse regulations and barriers remain in terms of APRN supervision by other disciplines, restricted prescriptive authority, lack of parity for insurance reimbursements, Medicaid policy that restricts telehealth psychiatric services to physicians, and APRN representation on decision-making bodies.3 This lack of uniformity is also a deterrent to the APRN Licensure Compact, which could benefit cross-border telehealth psychiatric services.

The behavioral health needs of patients, the distribution of current APRN resources, and the potential for future workforce resolution to professional shortages all need to be considered as we address the severity of the issues. Questions that could help guide our thinking focus on identifying any negative patient outcomes that have been reported because formally educated PMHNPs are not available. Has patient injury occurred? Are patients running, crazed and out of control, in the streets? Or, in the face of shortage and adversity, are APRNs doing what they can to provide care, promote access, and keep patients in their home communities?

A 2015 article examined how states define NP SOP language in relation to the tenets of the 2008 Consensus Document.4 Outcomes from the study identified that only 18 of 51 jurisdictions, including 50 states and the District of Columbia, had regulatory language that defined NP SOP by education and/or certification. Thus, a question about SOP needs further discussion. Are NPs who are not PMHNPs and whose primary practice involves psychiatric and behavioral health services in the 18 states that define SOP by education and certification more at risk for discipline by a regulatory board because they exceed their SOP?

Further study is needed to determine if there are outcome differences between behavioral health care provided by non-PMHNPs in these 18 states and NP care in the other 33 states that do not define differences in SOP definitions related to education and/or certification. If we continue supporting the current plan, we need to focus on resources that will help meet the need in terms of expanding PMHNP education programs, promoting the APRN license compact to enhance cross-border care, removing barriers to telehealth psychiatric services, and addressing continuing education for non-PMHNPs who are needed to continue treatment of behavioral patients.

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