Competence Isn't a Certificate: How Boards Actually Evaluate Scope and Clinical Judgment

This post examines how competence is actually evaluated in practice, and why certification alone neither guarantees mastery
nor determines defensible scope of care.

I see this come up repeatedly in clinician spaces, especially among PMHNPs: frustration, concern, or outright anger about FNPs working in psychiatric settings. The underlying fear is usually patient safety, and that concern is valid. Psychiatry is complex. Poor judgment can cause real harm.

But these conversations often collapse into a false binary: either someone is "allowed" to practice psychiatry because of a certification, or they are categorically unsafe forever. That framing does not reflect how scope, competence, or board oversight actually work in real practice.

Certification exams establish entry-level readiness. They do not define mastery, and they do not function as ongoing tests of competence at the point of care. When practice is questioned, boards do not re-examine clinicians. They review documentation, clinical reasoning, safeguards, and decision-making in context.

This post is not an argument that "anyone can do anything." It is an argument for proportionate practice. The defensibility of care depends on the complexity of the case, the intensity of treatment, the clinician's preparation and consultation, and how risk is managed and documented. Titles matter far less than reasoning when decisions are reviewed.

If we want to talk seriously about patient safety, we have to talk about how competence is demonstrated in practice, not just how it is certified on paper.

The Asymmetry No One Names Clearly

A newly graduated FNP is not competent to manage complex psychiatric illness any more than they are competent to independently manage advanced heart failure or end-stage renal disease on day one. The difference is this: FNP training is architecturally designed to develop depth through graduated responsibility, supervision, and mentorship across multiple clinical domains, including psychiatry. We already accept this developmental model in cardiology, nephrology, oncology, and hospitalist medicine. It is inconsistent to treat psychiatry as the one specialty where post-graduate training pathways suddenly become invalid.

PMHNP training, by contrast, achieves significant depth in psychiatric assessment and psychopharmacology but is not structurally designed to scaffold into longitudinal primary care management. A PMHNP ordering a TSH to rule out hypothyroidism as part of a depression workup is integration. Taking over thyroid management long-term is not, unless there is explicit dual training or a formal collaborative structure. That is not a limitation. It is a reflection of training architecture.

The pathways are not symmetrical because the foundational designs are different. Breadth does not guarantee depth, and depth does not guarantee breadth. What matters is whether the clinician can demonstrate proportionate training, consultation, and safeguards for the level of care being provided, and whether that reasoning is documented in a way that would survive retrospective review.

Certification, Scope, and Competence Are Not the Same Thing

Certification is a baseline standard. It confirms you met minimum requirements to enter a role safely. It does not prove mastery, and it does not define the outer limits of what you can do with appropriate training and oversight.

Scope is what your license could theoretically allow in principle. It is broader than most clinicians realize and varies significantly by state. Most NP scope-of-practice laws are competence-based, not specialty-restricted.

Competence is what you can safely do and defend in practice. It is built through training, supervision, experience, consultation, and ongoing education. It is not static. It grows and contracts based on your preparation, the clinical context, and the safeguards you have in place.

When a complaint is filed, boards do not stop to give you a test. They ask: What did you do? Why did you do it? Was it reasonable and safe in context? What did you document to support that reasoning? When did you consult, refer, or escalate?

That is how competence is judged in real-world oversight.

Integration vs Ownership: Where the Line Actually Is

This is where the abstract distinctions above turn into real clinical decisions.

A PMHNP can order and interpret medical data when it is directly tied to psychiatric differential diagnosis and safety monitoring. Ordering a TSH to rule out hypothyroidism in a patient with new-onset depression is defensible. Noting an abnormal result and coordinating referral to primary care is defensible. Adjusting levothyroxine as ongoing endocrine management is usually not defensible unless there is dual training, a formal role structure, or an explicit collaborative agreement.

The same logic applies in reverse. An FNP can assess and treat psychiatric conditions, including complex presentations, if they have developed depth through structured post-graduate training, supervision, mentorship, or specialty-focused practice. Managing depression, anxiety, ADHD, and even bipolar disorder or psychotic disorders can be defensible depending on the clinician's preparation, the consultation structure, and the safeguards in place. Certification did not grant that competence. Training and supervised practice did.

The boundary is not "what exam did you take." It is "can you demonstrate proportionate preparation, appropriate consultation, documented reasoning, and risk management relative to the complexity of care you are providing."

What Boards Actually Look At

When care is questioned, boards evaluate whether the clinician practiced within demonstrable competence. That means they look at:

Clinical reasoning documented in the chart Did the assessment make sense for the presentation? Were alternative explanations considered? Was the diagnosis supported by findings?

Treatment plan relative to complexity Was the intervention appropriate for the level of risk and acuity? Were safer or simpler options tried first when appropriate?

Risk identification and management Were safety concerns identified? Were appropriate safeguards put in place? Was the patient monitored appropriately?

Consultation and referral decisions Did the clinician recognize limits? Was consultation sought when needed? Were referrals made appropriately?

Documentation quality Does the chart tell a coherent story? Can another clinician follow the reasoning? Are decisions defensible based on what was known at the time?

None of these questions hinge on certification status. They hinge on judgment, preparation, and accountability.

Where Do You Draw the Line?

Competence is not binary. It is not "certified, therefore capable of everything" or "not certified, therefore incapable forever." It is a gradient that shifts with training, experience, consultation, and clinical context.

So here is the real question: Where do you personally draw your line between confidence and overreach? What is your rule for when you keep it, consult on it, or refer it? How do you know when you are practicing at the edge of your competence versus beyond it?

I am not asking what the board would say. I am asking what you use as your internal compass when the guidelines do not give you a clear answer.