Tegretol

"I didn't see no line GMS. I was just trying to get through the territory without getting scalped, that's all."

Jake Spoon-Lonesome Dove (1989)

As an advanced practice nurse, I increasingly feel like Jake Spoon in the above quote from the classic movie, Lonesome Dove. He says this line just as they are about to hang him for trespassing. Increasingly, I also don't see no line. The line I keep trying to see is the boundary, the delimiting fringe of where my practice should stop and within which my scope of practice should be contained. The line should be the boundary between my practice and that of an FNP for example. I keep thinking I should be able to see the line, but it is getting more and more blurry. I find reams of verbiage delineating my scope of practice. I tell my graduate students exactly what the scope and role functions of advanced practice psychiatric nurses are. I believe in the NONPF (2003) guidelines recently developed to boundary our practice. Yet, increasingly I cannot find the line. As an educator and practitioner, I am increasingly trying to get through the territory of healthcare systems, trying to meet the demands of the real world of practice, all the while trying not to get scalped for my efforts.

The Real World and Scope of Practice Issues

On paper it would appear that my lines are crystal clear; that my scope of practice is unique and distinct. Like all of my psychiatric APN peers, I am a clinical expert in psychiatric mental health care. I am licensed as an APN with prescriptive privileges. So why can't I see the line anymore? It has to do with many factors. It starts in the very philosophical issues that run in the veins of all nurses, our desire to care and help and be holistic. It continues in patients and the reality that they do not segment their health into neat little boxes. Patients do not have a sense of health as a compartmentalized, fractionated set of discrete symptoms and treatment needs. They come to us holistically, as a person feeling well or not so well. Holism lives and we as nurses conceptually resonate to it. But we establish our practices, our curricula, our standards and scopes of practices to represent compartments and categories of health that make the line more and more blurry. And finally, the blurring line has to do with the realities of health delivery in America and the needs of vulnerable patients with limited access and resources.

A patient, we will call her Jane, comes in to see me. Jane is homeless, indigent, and has just settled in Wyoming, a rural frontier state with more cattle than people, with one psychiatric and 28 community hospitals in the whole state. Jane gives a compelling history of bipolar disorder, and wants help being reestablished on the medications she has just run out of. As so many people do, Jane is struggling on the fringes of health and illness, and she knows herself well. Jane's worst fear is exacerbation of symptoms. Her symptoms are always just one stress away, one misstep, a stumble over the chronicity of illness. A wolf, she calls them, hidden but not ever really gone.

Jane wants this start in Wyoming to start differently; not with symptoms and with hospitalization but with health and functionality and adherence to the treatment she believes helps. Her history, as with the history of so many patients, supports that without medications she will spiral into a maelstrom of symptoms, disappearing social supports, hospitalizations, and mounting medical bills that pin her like a butterfly on a mount of continuing poverty for years to come. And so she wants me to prescribe her medications. It starts out with a clear line. Abilify and Tegretol and Wellbutrin. These are familiar and the line is sharp. Jane then discusses how much more stable her bipolar illness has been since she has been on her thyroid medication and can I please refill that. I am a psychiatric clinical expert. I understand the role of thyroid in mood stabilization and I have a prescriptive license that allows me to write for almost any drug, and Jane has no where else to go right now to get the thyroid drugs. And so, perhaps, I look over the line and then back to my side of it, and I write the script for thyroid. And then Jane is on to her need for oral birth control. She is sexually active, understands that she is at high risk for a complicated pregnancy and wants to avoid this, wanting to be healthy and proactive. Jane's need is reasonable and fitting. And so now, maybe, I straddle the line, looking past it just a bit, one foot in my true scope of practice, one foot on the top of the slippery slope that blurs the line. And then her antihypertensive needs come up. There is no one else to see her, she has no primary care provider, it is not yet an emergency, and no provider within 300 miles will take an uninsured patient. She has no money, and her blood pressure is rising, along with mine as I try to find the line.

The line blurs for countless reasons. Jane highlights many of them. She does not experience her health state as a collection of discrete categorical issues. She is well or not well. She needs a health provider and I am it today. She does not live the false dichotomy of brain-body that our scopes of practice imply. She lives in one of the richest countries in the world, experiences one of the most well-documented disabling illnesses, and yet, despite or maybe because of this, she has no health resources. No insurance, no money, scarcely a roof over her head, but she has a holistically rooted, firm sense of her health, and wants to be healthy. To see my line, I need to ask her to stop being holistic, to stop having an integrated sense of her health, and to parcel herself and the story of her health out, discussions of this part with me, discussions of this part not with me.

Jane is not unique. She is one of 45 million Americans lacking health insurance (U.S. Census, 2003), member of a not-so-exclusive club estimated to only grow. The percentage of Americans under 65 who have employer health insurance from 2001-2003 dropped from 67% to 60% (U.S. Census, 2003), and as a rural American her access issues are even further narrowed. Even if Jane had health insurance, the issue of blurred lines still remains. Millions of Americans have psychiatric illnesses co-occurring with common chronic illnesses like diabetes, CVD, and on and on. Many of America's primary care providers are stepping over the line into psychiatric care (McCabe, 2000). Jane's need for services is real, her perceptions of health as an integrative whole is as complex as it is compelling. But my worry over the line and over getting through the territory without getting scalped is real as well. As I step over the line, as I meet her needs, I risk litigious hazards for my caring, for violating professional standards, and overstepping scope of practice.

Don't misunderstand my line issues. I do not want or need to step over the line. I have no desire to blur it beyond recognition. I like knowing what I am an expert of and what I am not. I would like life much better if my practice world remained compartmentalized, if Jane could and would just cleanly and discretely have no health needs other than those that are boundaried by my skills, education, and experience. But as managed care manages some people out of services, as patients increasingly see psychiatric issues as health problems, as the number of uninsured, vulnerable Americans grows, I am losing that luxury. I wonder most compellingly which is my greater sin; to cross the line, to blur it and make it harder to see, perhaps helping Jane but risking my professionalism, or to rigidly adhere to the line, leaving me safe from scalping but leaving a gaping hole in the center of Jane's health.

I suspect I am not alone in increasingly having difficulties in seeing the line. I recently had a series of discussions with an FNP colleague, Mary Burman, a wonderful, compassionate, clinical expert practitioner who is increasingly having difficulty seeing her side of the line. She sees the Janes of the world in reverse. They come to her needing thyroid drugs, antihypertensives, and her line is clear. Then they need their Prozac renewed, their Neurontin or Zyprexia filled, and so she too steps over the line. Carefully, thoughtfully, but nonetheless over she goes. And after awhile, she too doesn't see no line. And her fear of getting scalped with the razor blades of litigious and professional concern mounts every time she steps over, a feeling always juxtaposed with morality issues about what happens, not in the abstract, but in the flesh-and-blood real person standing in front of her, if she does not blur the line.

And so, we need to talk. I suspect the line is getting harder to see for all of us. Where does our practice boundary take us? How firm is it? How firm should it be? These are important questions on many levels. And what does it say that the line cannot be seen easily. Perhaps we need to take back the line, be clear of who we are and what we do. Or perhaps it is for the better. Perhaps the blurring, the disappearing line highlights the growth of advanced practice nurses and our need to reconceptualize what we are and what we do.

I have spoken and written in the past about the growing trend of primary care settings becoming the point of care for many common psychiatric problems. This trend is well documented and encouraged by many. It is a trend that at this time is hard to reverse, and that seems to call for either a renegotiation of the scopes of practice of primary and specialty care advanced nurse practitioners, or a formal acceptance that blurred lines are real or professionally tolerated. But before we go there, we need to talk. We need to think about the implications of such acceptances. Should any FNP treat any and all depressions? At what point should a specialist be involved? If a patient fails to respond to an initial treatment, should they continue treatment with an FNP or be referred to a psychiatric APN? Conversely, should I or any psychiatric APN treat pneumonia, diabetes, hypothyroidism? Is there ever a reason to do so? Is the interest and the experience of the FNP or psychiatric APN to be considered, rendering the issue a case-by-case consideration of scope of practice? Where is the line in the sand beyond which no situation warrants stepping over the one's scope of practice?

The questions are numerous and the answers non-existent at present. I believe this is a critically important issue for all of us, legally, morally, practically, and futuristically. The very identity that we have of ourselves as psychiatric nurses is shaped by the uniqueness we offer the profession of nursing. If we are not different from our fellow nurses in some measurable way, we need to know that. If we are different, we need to protect that scope of practice from wellintended but inappropriate encroachment. Conversely, we need to know if we boarder on encroachment. These questions and the potential answers will reverberate in many ways and in many places. What are the curricular implications? How should we configure practice agreements? Should we revise the standards or the models of service delivery we have come to know so well?

Perhaps we are watching the start of an evolution. An iterative process that is bringing the pendulum of masters-level nursing back to the center. National movements are calling for the development of a generalist masters-prepared nurse, the Clinical Nurse Leader degree (AACN, 2003). Discussions of a nursing practice doctorate are increasingly gaining favor (AACN, 2004). The blurred line may be the start of the movement towards expanding the impact of nurses on the total health of individuals. But before we get there, I still need us to talk about where the line is. I need us to talk because the Janes of the world keep coming to me and I still don't see no line. So lets talk...

References

American Association of Colleges of Nursing. (2003). Working paper on the role of the clinical nurse leader. Retrieved November 12, 2004, from http://www.aacn.nche.edu/Publications/WhitePapers/ ClinicalNurseLeader.htm.

American Association of Colleges of Nursing. (October, 2004). Position statement on the practice doctorate in nursing. Retrieved November 12, 2004, from http://www.aacn.nche.edu/DNP/ pdf/DNP.pdf.

McCabe, S. (2000). Bringing psychiatric nursing into the twenty-first century. Archives of Psychiatric Nursing, 34(3), 109-116.

National Organization of Nurse Practitioner Faculties (2003). Psychiatric-mental health nurse practitioner competencies. Washington, D.C.: Author.

U.S. Census Bureau. (2003). Statistical abstract of the United States: The national data book. Washington, D.C.: Author.

Susan McCabe, EdD, APRN, BC

Author contact: smccabe321@comcast.net, with a copy to the Editor: mary@artwindows.com

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