April 16, 1999

By Richard Karel

For the fourth time in five years, Maryland legislators have killed a bill that would have permitted nurse psychotherapists to prescribe medication.

"Defeat of the nurse psychotherapists' proposal is a resounding endorsement of psychiatry's position that individuals with mental illnesses should not be subjected to a lesser standard of care than is accorded persons with other medical illnesses," said Katherine Becker, J.D., deputy director for state affairs in APA's Division of Government Relations. The collaboration of the Maryland Psychiatric Society (MPS), with help from APA, and the state medical society was instrumental in the defeat of the legislation, Becker added.

Like a cat with nine lives, the nurse psychotherapist prescribing legislation has come back year after year, bolstered by the efforts of a number of nurse legislators in the Maryland House of Representatives, according to Steve Daviss, M.D., cochair of the MPS legislative committee. At least six Maryland delegates are nurses, he noted.

Opponents of the nurse prescribing bill were fortunate, however, in that one of the key players on the House committee assigned the legislation was a physician, said Daviss.

That physician, Delegate Daniel Morhaim, M.D., "helped cut through some of the rhetoric and described the complexity of prescribing psychotropic medications," said Daviss. "And he successfully explained [to other legislators] why a psychiatrist with a minimum of eight years' education and training is preferable to a nurse."

In Maryland, clinical nurse specialists may enroll in a three-semester master's program that focuses on psychotherapy and includes one three-credit course in psychopharmacology to become nurse psychotherapists, explained Daviss. "That's the extent of their education and preparation for prescribing medications," which would have been acceptable under the bill, Daviss said.

In Maryland nurse psychotherapists have "a completely independent practice with no physician supervision whatsoever," he noted. They have wanted to maintain that independence while expanding their scope of practice.

Under Maryland law, nurse practitioners (as opposed to nurse psychotherapists) are able to prescribe in collaboration with a physician, who must review all of the nurse's files, explained Daviss. The physician does not have to authorize individual prescriptions.

The defeat of the nurse psychotherapist prescribing bill in a lopsided 3-to-18 vote (its worst defeat since its introduction five years ago) was aided by the advent of a new University of Maryland-based program specifically designed to train psychiatric nurse practitioners, explained MPS lobbyist Franklin Goldstein, J.D. Although Maryland nurse practitioners already have prescribing authority, the new program is designed to turn out a nurse practitioner trained in psychotherapy, he said.

The program, which takes a year longer to complete than the master's-level clinical nursing program for nurse psychotherapists, will graduate its first psychiatric nurse practitioners in one year, according to Daviss. Those nurses will work in collaboration with a physician who will review all files, including those cases where the nurse chooses not to prescribe, explained Goldstein. "The MPS feels that the decision not to prescribe is also a medication decision and that a physician should be involved," he noted.

According to a position statement posted on its Web site, the American Psychiatric Nurses Association (APNA) supports the extension of prescribing privileges to any master's-level registered nurse who is certified as a specialist by the American Nurses Credentialing Center; has "demonstrated competence in physical assessment, neuroscience, and clinical psychopharmacology"; and undergoes "advanced educational preparation."

Among the more than 40,000 clinical nurse specialists now in practice in the United States, about 7,000 are credentialed as specialists by the American Nurses Credentialing Center, according to APNA.

Current APNA President Jane Ryan, R.N., M.N., spoke with Psychiatric News.

"APA has the stance that a medical education and residency is the only path to prescribing," said Ryan. "But state law recognizes other providers" as qualified to prescribe. "For APA it's a bread-and-butter issue. For APNA it's an access issue. We believe that patients should have access to high-quality mental health care by qualified providers."

Currently 41 states permit psychiatric clinical nurse specialists and psychiatric mental health nurse practitioners to prescribe, she noted.

The basic educational requirements "are the same whether you are a nurse practitioner or a clinical nurse specialist," said Ryan. "We're not saying all clinical nurse specialists should have prescriptive authority; we're saying qualified clinical nurse specialists should have that authority."

APNA has no position on whether nurses should be able to practice independently or only under physician supervision, said Ryan.

The curriculum for nurse practitioners and clinical nurse specialists varies somewhat from state to state, which is why APNA has set uniform standards for prescriptive authority, Ryan commented. The current availability of federal money for nurse practitioner programs such as that at the University of Maryland "has been instrumental in the development of these programs," she noted. In the 1970s, federal funds were channeled toward clinical nurse specialist programs, whereas now funds are going toward advanced nurse practitioner programs, Ryan said.

Nurse practitioners already receive significant medical training, observed Daviss. "The focus of the new University of Maryland program is to be able to have nurse practitioners adept at treating psychiatric patients under a physician's supervision," said Daviss. "That's the type of nurse who would be better suited to manage some of these patients."

But Daviss pointed out that under Maryland law nurse practitioners can treat only acute medical illnesses or chronic, stable illnesses, and may thus be ineligible to treat some psychiatric disorders.

"A psychotically depressed, suicidal patient really fits neither of those categories, so it remains to be seen what the actual role of the psychiatric nurse practitioner will be in Maryland," Daviss said.

While the past suggests that nurse psychotherapists will try again to get prescribing privileges through legislation, Daviss is optimistic that the advent of the psychiatric nurse practitioner program will render the issue of nurse psychotherapist prescribing moot in Maryland. The nurse psychotherapists "have essentially been trying to become nurse practitioners through legislation rather than additional training," said Daviss. "Our point all along has been that they need to go back and get the additional training."

Related information can be found on the Internet at www.mdpsych.org/~mdpsych/ and www.apna.org/presauth.htm.