On Friday, April 3, the Massachusetts Department of Mental Health (DMH) issued an emergency expansion of what nurse practitioners are allowed to do on psychiatric inpatient units.
For the duration of the COVID related state of emergency, NPs can now:
- Assess whether a patient is competent to sign in voluntarily to the hospital (called a Section 10/11 or “conditional voluntary”)
- Assess whether a patient may need to be admitted involuntarily because of danger to self or others (called a Section 12, or a 3 day hold, or in many states, a “pink slip”)
- Order emergency restraints for patients who become violent to self or others
- Examine a retrained or secluded patient within 1 hour of the restraint
For those of us living and breathing (now a through a face mask) inpatient psychiatry, these arcane sounding authorities are crucial to the operation of a unit. Until yesterday, Massachusetts regulators required that only psychiatrists could sign off on these specialized assessments and forms. For many years, nursing groups and many doctors have been lobbying DMH to allow nurses these functions, because there is really no clinical justification for the restriction. NPs are already acknowledged to have great competency in psychiatric care and are allowed to admit, evaluate, and medicate psychiatric patients—almost independently (the state requires flexible supervision by psychiatrists). We trust NPs with the most complicated clinical tasks—but signing a pink slip? No, that’s the doctor’s job.
These archaic regulations have meant that hospitals have had to recruit and pay top dollar to psychiatrists so that they could hang around just in case these situations came up. The COVID pandemic has forced DMH’s hand to loosen these restrictions, because if the attending psychiatrists become ill, hospitals would be forced either have NPs take over these duties, or, if they were not allowed to do so, the hospital would have to close down.
This new announcement is an implementation of Governor Baker’s shrewd emergency order on March 27 temporarily authorizing NPs in all specialties to practice without physician supervision (https://www.mass.gov/news/baker-polito-administration-announces-travel-guidelines-and-new-health-care-resources-to).
The silver lining of this treacherous pandemic is that it forces us to scrutinize business-as-usual health care practices. Many of the old rules and regulations have been temporarily relaxed, such as HIPAA rules that have made telehealth hard and expensive to implement. Those of us who have long chafed under these regs are hoping and praying that when the state of emergency is over, a state of enlightenment will dawn.