(2019)Fact Sheet: An Act to Improve access to care by removing barriers to practice for Psychiatric Clinical Nurse Specialists

Sponsored by Representative Kay Khan and Senator Joan Lovely

What this bill does:

This bill removes the requirement that a psychiatric clinical nurse specialist must be supervised by a physician to write prescriptions and order tests and therapeutics. The supervisory requirement would be removed only after a two-year period of supervision of the psychiatric clinical nurse specialist by a physician, or nurse practitioner or psychiatric clinical nurse specialist in independent practice.

Why this bill is needed:

In all regions of Massachusetts, there is a shortage of mental health care.  The difficulty accessing care is particularly acute for certain populations, including MassHealth members, residents of rural areas, and children.

At the same time,  in Massachusetts, health care comes at a high cost.  In 2018, MassHealth represented 37 percent of the state budget prior to Federal reimbursement, and 24 percent after Federal reimbursement, heightening the importance of care that is not only high quality but also cost-effective.

Ensuring access to timely mental health and substance abuse care would reduce the need for expensive emergency and inpatient treatment, ameliorate the opiate crisis, and reduce other societal costs, resulting in improved productivity and public health and safety.

Removing the unnecessary practice barrier that is career-long physician supervision will help  address issues of cost and access, and help Psychiatric Clinical Nurse Specialists better serve residents of Massachusetts.

Who are Psychiatric Clinical Nurse Specialists, and How Can They Help?: Psychiatric Clinical Nurse Specialists (CNS) are registered nurses, educated at the master’s level or above in the biological and psychological sciences, and authorized to practice as advanced practice nurses by the Massachusetts Board of Registration in Nursing.  Psychiatric CNSs conduct psychotherapy and prescribe psychiatric medications.  The field, developing over the past 60 years, gained prescriptive authority in Massachusetts in 1994.  Psychiatric CNSs provide cost-effective, high quality care.

  • Not only are Psychiatric CNS reimbursement rates generally lower than psychiatrists, but both the Institute of Medicine (Future of Nursing Report, 2010) and the Federal Trade Commission (FTC, 2014) recommend removal of career-long physician supervision of advanced practice nurses as a way to encourage innovation and reduce cost.
  • Outcomes of Psychiatric CNSs are comparable to psychiatrists. Studies show similar prescribing practices between advanced practice psychiatric nurses and psychiatrists (Feldman, Bachman, Cuffel, Friesen and McCabe , 2003; Fisher and Vaughan-Cole, 2003) and no difference in patient adherence to treatment regimens (Jacobs, 2005).
  • Malpractice claims are fewer, and malpractice insurance is less expensive, for advanced practice nurses than for physicians; and studies have found fewer malpractice claims are associated with no direct physician supervision of advanced practice nurses, including clinical nurse specialists (NSO Nurse Practitioner Surveys, 2009 and 2012).
  • After over 20 years of prescriptive practice, the knowledge and capabilities of psychiatric nurse mental health clinical specialists have significantly expanded, making the original law requiring physician supervision out of date and unnecessary.
  • While Massachusetts was at the forefront in establishing universal healthcare, we currently lag behind our neighbors in removing the requirement of career-long supervision of advanced practice nurses, which is a significant barrier to practice. Currently, we are the only New England state yet to remove this barrier.
  • Removing the barrier of career-long supervision for Psychiatric CNSs would help retain an experienced workforce. A 2017 survey of 124 Massachusetts advanced practice psychiatric nurses, predominantly Psychiatric Clinical Nurse Specialists, who were collectively treating a total of  26,554 patients, showed that 95 percent had been prescribing psychiatric medications for 6 or more years, and 76 percent had been prescribing for 11 years or longer.  Additionally, the average age of the group’s supervising psychiatrists was 59.
  • As supervising psychiatrists retire, they can be costly and difficult to replace. Twenty percent of Psychiatric Clinical Nurse Specialists surveyed indicated that they had been unable to work in the past for lack of a supervising psychiatrist, and 20% also indicated that if their supervising psychiatrists retire they themselves will retire or consider retiring.  Updating Massachusetts law to remove the career-long supervisory requirement for experienced Psychiatric Clinical Nurse Specialists would help avert worsening shortage by improving workforce retention.

Support grows for removing barriers to practice for advanced practice nurses:

  • Twenty-eight states plus the District of Columbia have independent prescriptive authority for clinical nurse specialists. (National Association of Clinical Nurse Specialists, 2019). Legislation to grant independent practice is in process in several other states.
  • All New England states, and all neighboring states, now have independent practice for advanced practice nurses.
  • The American Nurses Association (2007) identifies advanced practice registered nurses as “professionally qualified to assume responsibility for clinical functions. They are accountable for their own practice and are prepared to perform services independent of other disciplines in the full range of delivery settings.” ( p. 20)
  • The Association of Academic Health Centers said the “lack of uniformity of scope of practice laws limits professionals mobility and practice” and that “expanding the scope of practice of various health care professionals…would increase access to care” (AAHC, 2008 pp. 21, 26, 27).
  • The Rand Report for the Massachusetts Division of Health Care Finance and Policy has recommended independent practice for APNs (Eiber, Hussey, Ridgely and McGlynn, 2009).
  • The Engelberg Center for Healthcare Reform at Brookings Institute (2009) weighs in on the need to amend the scope of practice of advanced practice nurses and other groups.
  • The landmark Institute of Medicine report on The Future of Nursing (2010) recommends federal and state action to update regulations so that all advanced practice nurses may practice to the full extent of their education and training. This is to ensure all Americans have access to needed health care, and nurses’ unique contributions to the health care team are maximized. (p. 1-8)
  • The Affordable Care Act took a variety of steps to remove barriers to practice for advanced practice nurses, recognizing how these professionals can help increase access to care.
  • Both sides of the aisle support this and similar bills. Governor Baker has announced that one of his priorities for this legislative session is to update licensure laws to improve access to high quality, cost-effective care.

For further information contact:

Mary Ann Hart  617 797-8488



AAHC (Association of Academic Health Centers). 2008. Out of Order, Out of Time: The State of the of The Nation’s Health Workforce. Washinton, DC: AAHC. Retrieved from

http://www.aahcdc.org/policy/AAHC_OutofTime_4WEB.pdf .

American Nurses Association, American Psychiatric Nurses Association, International Society of Psychiatric-Mental Health Nurses. 2007. Psychiatric-Mental Health Nursing: Scope and

Standards of Practice Silver Spring, MD:  American Nurses Association.

Burnett-Ziegler, I. et. al. (2012). Prevalence and correlates of mental health problems

and treatment among adolescents seen in primary care, Journal of Adolescent

Health, 50(6), 559-564.

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the

Institute of Medicine of Medicine. 2010. Future of Nursing: Leading Change,

Advancing Health. Washington, D.C.: National Academy Press, pre-publication copy, p. 1-8.

Rev. 1/19/19

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