Blueprint for development of the advanced practice psychiatric nurse workforce

Analysis of Mental Health Workforce: Implications for Social Work Practice and Profession

This analysis was undertaken to better understand what factors may contribute to the relative strength or weakness of the clinical social work professional workforce. We explored the relationship between social work workforce numbers and social work licensure laws/policies. We also examined relationships between population factors and mental health workforce, including examining ratios of other mental health professions nationwide. Additionally, we explored mental health workforce strengths as it relates to state mental health needs and utilization of mental health services. Our findings were consistent with past research with respect to proportion of overall mental health workforce across mental health professionals. We did not find a direct relationship between licensure laws/policies and state social work workforce numbers. However, we found some relationships between the ratio of social workers to the population and state health rank, as well as the overall mental health workforce availability in a state. In addition, a relationship was found between ratio of social workers to the population and adults with mental illness not receiving care. Given the results, the authors posit that these findings could be used to promote the social work discipline in targeted ways, such as promotion of the discipline in states where mental health needs are underserved or in states with lower health rankings. Factors to consider at the macro and micro levels, as well as interprofessional issues in training and work, are discussed. We believe the findings from this analysis can be used to inform policy and promote the discipline of social work.

How collaborative practice agreements impede the provision of vital behavioral health services

BACKGROUND

The critical shortage of behavioral health professionals impairs the ability of the U.S. health care system to respond to the growing demand for services to address mental illness and substance use disorders.

PURPOSE

To identify how restrictive state regulations act as barriers to full utilization of psychiatric mental health advanced practice registered nurses (PMH-APRN), whose scope of practice enables them to provide a full range of behavioral health services.

METHODS

A sequential mixed methods study combining interview data (n = 94) from a qualitative study of PMH-APRN practice with a subset of quantitative data (n = 699) from a national APRN survey examining the impact of state-mandated APRN/MD collaborative practice agreements.

DISCUSSION

Data sources converged to portray challenges to optimal use of APRNs providing psychiatric/mental health services, including high out-of-pocket fees, irregular communication with supervisors, mandated chart reviews, and supervisor turnover.

CONCLUSION

Inconsistent and burdensome supervision requirements contribute to cost inflation and may limit patient access.

The Distribution of Advanced Practice Nurses Within the Psychiatric Workforce

OBJECTIVE: To examine the size and distribution of the advanced practice psychiatric nurse workforce relative to the total psychiatry workforce to determine whether nurses are predominantly working in areas with higher or lower levels of behavioral health specialists. METHODS: State-level data for psychiatric nurses were obtained from the American Nurses Credentialing Center, and included mental health psychiatric nurse practitioners, adult psychiatric nurse practitioners, child psychiatric clinical nurse specialists, and adult psychiatric clinical nurse specialists. Supply estimates of the full psychiatry workforce were calculated for comparison purposes. State population estimates were obtained from U.S. Census Bureau data. State workforce estimates were converted to a 1:100,000 provider-to-population ratio to analyze the density of providers across states. RESULTS: In 2018, the psychiatric workforce supply was estimated to be composed of 66,740 providers, including psychiatrists (n = 47,046; 71%), psychiatric nurses (n = 17,534; 26%), physician assistants (n = 1,164; 2%), and psychiatric pharmacists (n = 966; 1%). Overall, psychiatric providers appeared to be most densely concentrated in the northeast region of the United States. A dearth of providers was most pronounced within areas in the 12-state Midwest region, southern states, California, and Nevada. The average concentration of psychiatric workers was 22.61 per 100,000 population. CONCLUSIONS: The findings of this study find inconsistent pattern of how psychiatric nurses are distributed relative to the rest of the workforce, but reinforce the idea that they are essential in addressing care needs in areas with low concentrations of psychiatry specialists-especially if they are authorized to work to the full extent of their training/education.

The Medicalization of Nursing: The Loss of a Discipline's Unique Identity

The authors propose that the evolution of the role development for generalist and advanced practice nursing is increasingly at odds with the contemporary scholarship of the discipline and ultimately betrays the unique identity and autonomy of the nursing profession. The development of the evidence-based practice movement in medicine and nursing is explored as the predominant theoretical framework guiding nursing practice. Professional challenges and recommendations to reclaim the unique nature of nursing are discussed with attention to the implications for the educator, clinician, and scholar.

A scoping review of nurse practitioner workforce data: Part two of a four-part series on critical topics identified by the 2015 Research Agenda Roundtable

BACKGROUND AND PURPOSE

There is no single comprehensive data source for conducting nurse practitioner (NP)-focused workforce and outcomes research. The 2015 Research Agenda Roundtable of the Fellows of the American Association of Nurse Practitioners supports the development of a national NP data source. A scoping review was conducted to provide an overview of data being used in NP-focused research and to identify key issues relevant to making progress toward a national NP database.

METHODS

PubMed, CINAHL, and EMBASE were searched for English-language articles published within the past 10 years (2007-2017). Twenty-one articles were included for review and categorized into three themes: 1) NP Workforce Data Collection and Availability; 2) Using Data to Identify NPs; and 3) Minimum Data Sets and Key Variables.

CONCLUSIONS

General consensus among workforce experts suggests that rich sources of NP data exist. However, challenges include a lack of a national data source for studying the NP workforce and outcomes; the inability to identify individual NP providers within existing data; and variations in how different sources of data are collected.

IMPLICATIONS FOR PRACTICE

Improved NP workforce data collection is vital for workforce planning and forecasting and has implications for outcomes research and NP workforce distribution and employment.

Utilization and Economic Contribution of Psychiatric Mental Health Nurse Practitioners in Public Behavioral Health Services

INTRODUCTION

Expanded insurance coverage through the Affordable Care Act and parity in behavioral health coverage have increased demand for services. Yet there is a persistent shortage in the behavioral health workforce. Psychiatric Mental Health Nurse Practitioners (PMHNPs) may be part of the solution to shortages but are not yet fully utilized. The purpose of this study was to describe how PMHNPs are utilized, identify barriers to full utilization, and assess PMHNPs' economic contribution in public behavioral health systems.

METHODS

This study used a mixed methods approach, selecting counties for use of PMHNPs, geography, population size, rural/urban, and availability of financial data. The authors conducted 1- to 2-day site visits in 2014-2015 including semi-structured interviews with management and clinical leaders and collected PMHNP staffing and billing data. Thematic analysis of interview data was conducted and aggregate staffing and billing data were analyzed to determine net PMHNP financial contribution.

RESULTS

The primary billed service for PMHNPs is medication management. Barriers to full utilization included system-level barriers to hiring PMHNPs, lack of role-appropriate job descriptions, confusion related to scope of practice/supervision requirements, and challenges in recruitment and retention. Fiscal analysis showed a positive net contribution from PMHNP services.

CONCLUSIONS

PMHNPs can make a significant contribution to behavioral healthcare delivery, particularly in public mental health settings, yet greater understanding of their role and addressing barriers to practice is needed.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Quality of Life and African American Women Who are Family Caregivers: A Literature Review with Implications for Psychiatric Mental Health Advanced Practice Registered Nurses

PURPOSE

To identify factors affecting the quality of life (QOL) of African American women (AAW) family caregivers of individuals with kidney failure.

METHODS

Ferrans' Conceptual Model of QOL provided the framework for this literature review. Included studies were (a) peer- reviewed, (b) published within the last ten years, (c) written in English, and (d) examined QOL of AAW family caregivers. Using CINAHL© and PubMed©, we found 14 studies that described factors associated with these caregivers' QOL.

SCOPE

Few studies document the QOL of AAW who are family caregivers, especially in the context of kidney failure. Psychiatric Mental Health Advanced Practice Registered Nurses need to learn about the factors influencing the QOL of these caregivers.

RESULTS

No studies were found within the last ten years that explored the QOL of AAW family caregivers of individuals with kidney failure. Findings reflected the QOL of AAW family caregivers in the context of other chronic conditions. Various factors such as stress, insomnia, and employment were linked to an impaired QOL. Implications for practice, research and education for PMH-APRNs are suggested.

CONCLUSION

PMH-APRNs are uniquely trained to address many factors that affect the QOL of these caregivers and may provide holistic care aimed at promoting satisfactory QOL for these caregivers.

An Efficient Nurse Practitioner-Led Community-Based Service Model for Delivering Coordinated Care to Persons With Serious Mental Illness at Risk for Homelessness [Formula: see text]

BACKGROUND

Access to mental health care is a struggle for those with serious mental illness (SMI). About 25% of homeless suffer from SMI, compared with 4.2% of the general population.

OBJECTIVE

From 2003 to 2012, St. Paul's Center (SPC) operated a unique model to provide quality care to the homeless and those at risk for homelessness, incarceration, and unnecessary hospitalization because of SMI. Data were available for analysis for the years 2008 to 2010.

DESIGN

The SPC was developed, managed, and staffed by board-certified psychiatric/mental health nurse practitioners, offering comprehensive mental health services and coordinated interventions.

RESULTS

All clients were housed and none incarcerated. From 2008 to 2010, only 3% of clients were hospitalized, compared with 7.5% of adults with SMI. Clinical, academic, and community partnerships increased value, but Medicaid reimbursement was not available.

CONCLUSION

Mental health provisions in the recently passed 21st Century Cures Act support community mental health specialty treatment. The SPC provides a template for similar nurse practitioner-led models.

Expanding rural access to mental health care through online postgraduate nurse practitioner education

BACKGROUND AND PURPOSE

Workforce shortages in mental health care are especially relevant to rural communities. People often turn to their primary care providers for mental healthcare services, yet primary care providers indicate that more education is needed to fill this role. Rural primary care nurse practitioners (NPs) are ideal candidates for educational enhancement. Online programs allow NPs to continue living and working in their communities while developing the competencies to provide comprehensive and integrated mental healthcare services. This article presents a review of current online postgraduate psychiatric mental health NP (PMHNP) options.

METHODS

Website descriptions of online PMHNP programs were located using keywords: PMHNP or psychiatric nurse practitioner, postgraduate or post-master's, and distance or online.

CONCLUSIONS

Across the United States, 15 online postgraduate certificate programs were located that are designed for primary care NPs seeking additional PMHNP specialization.

IMPLICATIONS FOR PRACTICE

For rural primary care NPs who are ready, willing, and able, a postgraduate PMHNP specialty certificate can be obtained online in as few as three to four semesters. The expected outcome is a cadre of dually credentialed NPs capable of functioning in an integrated role and of increasing rural access to comprehensive mental healthcare services.

Experience of Psychiatric Mental Health Nurse Practitioners in Public Mental Health

Expansion of health insurance coverage under the Accountable Care Act has meant that millions of people are now insured for mental health treatment, but with no significant increase in the mental health workforce. Services of psychiatric mental health nurse practitioners (PMHNPs) may be best utilized to improve access to and quality of public mental health services if the financial, political, scope of practice, and treatment model barriers that limit their ability or willingness to practice in these settings are better understood. This article reports qualitative results from a study that assessed barriers and best practices in the use of PMHNPs in county mental health services in California. Results indicate that PMHNPs are valued for their "whole person" perspective, collaborative approach, and interpersonal communication skills, but that significant knowledge gaps, regulatory constraints, and bureaucratic barriers in public mental health systems inhibit PMHNPs from practicing at the top of their scope.

Integrating the 2013 Psychiatric Mental Health NP Competencies Into Educational Programs: Where Are We Now?

Since the introduction of the revised National Organization of Nurse Practitioner Faculties (NONPF) Nurse Practitioner Core Competencies and Population Focused Psychiatric Mental Health Nurse Practitioner (PMHNP) Competencies, a national forum took place to hear from many PMHNP program directors in the field comparing how they have integrated the lifespan competencies and the master's (MS)/or doctor of nurse practice (DNP) essentials into their curriculum. In this paper, we will report first on the major areas of change in the structure and content of the PMHNP-lifespan curriculum as well as the comments made by many faculty from across the country as to challenges and innovative strategies used to meet these challenges. We will review some of the major issues in content, pedagogy, and evaluation methods as well as examples of how these curricular elements have been infused into select programs across the country. We conclude highlighting several key areas, suggested foci for change, and how the specialty might focus attention and accelerate the significant growth we are seeing in PMHNP programs.

Exploring the Needs for Support of Pediatric Nurses Caring for Children with a Mental Health Disorder Hospitalized in Non-Psychiatric Units

This qualitative study explored the experience and the needs for support of pediatric nurses caring for children with a mental health disorder hospitalized in non-psychiatric units in a health organization in Canada. Semi-structured interviews were conducted with 17 nurses. Content analysis revealed two main themes: (a) nurses are challenged by the lack of knowledge, the gap between access to mental health resources and the basic role of only ensuring safety. Amidst these barriers, nurses revealed their feelings of helplessness, frustration and injustice. (b) All participants voiced their willingness to break this powerlessness loop. They identified several strategies to support them: more training in mental health, better collaboration with the mental health team, etc. Further research is needed to evaluate the efficiency of these strategies to improve the delivery of care for children with a mental health disorder hospitalized in non-psychiatric units.

Psychiatric Mental Health Nursing Workforce Agenda: Optimizing Capabilities and Capacity to Address Workforce Demands

BACKGROUND

The mental health service delivery transformation has created models of care that generate demand for a workforce with particular competencies.

OBJECTIVE

This article develops a psychiatric mental health (PMH) nursing workforce agenda in light of demand generated by new models of care and the capacity/capabilities of the PMH RN and advanced practice nurse (APN) workforce.

DESIGN

Examine the current capacity of the PMH nursing workforce and how health care reform and related service delivery models create demand for a particular set of behavioral health workforce competencies.

RESULTS

PMH RNs and APNs have an educational background that facilitates development of competencies in screening, care coordination, leveling care, and wellness education. PMH RNs are a large workforce but the size of the PMH APN group is inadequate to meet demand.

CONCLUSION

The specialty must strategize on how to build requisite PMH RN and APN competencies for the evolving service landscape.

La pratique infirmière avancée : un choix qui s’impose pour la qualité des soins et services en santé mentale

La refonte des lois professionnelles et la réorganisation des services en santé mentale ont eu une influence significative sur la pratique infirmière en santé mentale au Québec. De nombreuses infirmières ont fait preuve de leadership clinique et ont su adapter leurs services aux besoins de la population selon les nouveaux milieux de soins de proximité. Cependant, plusieurs sont d’avis que le rôle des infirmières n’est pas suffisamment connu et mis à profit pour contribuer de façon optimale à l’offre de services en santé mentale. Ainsi, cet article porte un regard critique sur la pratique infirmière en santé mentale au Québec et les conditions essentielles à son évolution. Il vise à : 1) décrire les tendances actuelles qui caractérisent l’évolution des rôles et la modernisation de la pratique infirmière en santé mentale au Québec ; 2) offrir un aperçu de l’évolution de la pratique infirmière avancée en santé mentale (PIA-SM) et de ses retombées sur la qualité des services ; 3) clarifier le concept de PIA et situer son évolution au Québec ; et 4) proposer diverses stratégies visant à optimiser le rôle des infirmières et leur complémentarité avec les autres professionnels dans l’offre de services en santé mentale. Les progrès en cours sont illustrés par des exemples de pratiques innovantes développées par des infirmières québécoises dans le contexte de la restructuration des services de santé. Les données quant à l’évolution de la PIA-SM aux États-Unis et en Australie indiquent qu’il existe encore de nombreux défis liés à l’implantation réussie de ce nouveau rôle. Toutefois, il se dégage, de la majorité des études, un consensus de plus en plus important quant à la contribution de la PIA-SM pour améliorer la qualité et l’accessibilité des soins en santé mentale. La réforme des services de santé mentale au Québec s’avère donc être un moment propice pour développer et soutenir la PIA-SM et en retirer les bénéfices attendus.

Patient-centered medical homes: presenting a role for the advanced practice mental health nurse

As the burden of mental illness grows in the United States, recent data show that many in need of behavioral health services are not currently receiving them. Recent passage of the Patient Protection and Affordable Care Act has presented an opportunity to change the delivery of behavioral health care to a consumer-driven, evidence-based model geared toward the coordination of care within the primary care setting. Psychiatric-mental health clinical nurse specialist/nurse practitioners are in an ideal position to deliver cost-effective behavioral health care in collaboration with primary care providers under the new patient-centered medical home model of care.

Organizational fidelity to a medication management evidence-based practice in the treatment of schizophrenia

Organizational support is essential for successful implementation of evidence-based practice (EBP) in clinical settings. This 3-year study used a mixed qualitative and quantitative design to implement a medication management EBP in the treatment of schizophrenia in six community mental health clinics in a south-central state of the United States. Findings from organizational fidelity assessments indicate that support for EBP implementation was moderate. Organizational support was highest for prescriber access to relevant patient information at each medication visit, scheduling flexibility for patients' urgent problems, and availability of medication guidelines. Organizational support was lowest for medication availability and identification of treatment refractory patients. Findings suggest that leadership is essential to support successful implementation. Nurse educators can incorporate implementation research and leadership training into graduate nursing programs to facilitate successful EBP implementation in practice settings.

A needs-based method for estimating the behavioral health staff needs of community health centers

BACKGROUND

Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed.

METHODS

Using health center staffing data and behavioral health service patterns from the 2010 Uniform Data System and the 2010 National Survey on Drug Use and Health, we estimated the number of patients likely to need behavioral health care by insurance type, the number of visits likely needed by health center patients annually, and the number of full time equivalent providers needed to serve them.

RESULTS

More than 2.5 million patients, 12 or older, with mild or moderate mental illness, and more than 357,000 with substance abuse disorders, may have gone without needed behavioral health services in 2010. This level of need would have required more than 11,600 full time providers. This translates to approximately 0.9 licensed mental health provider FTE, 0.1 FTE psychiatrist, 0.4 FTE other mental health staff, and 0.3 FTE substance abuse provider per 2,500 patients. These estimates suggest that 90% of current centers could not access mental health services or provide substance abuse services to fully meet patients' needs in 2010. If needs are similar after health center expansion, more than 27,000 full time behavioral health providers will be needed to serve 40 million medical patients, and grantees will need to increase behavioral health staff more than four-fold.

CONCLUSIONS

More behavioral health is seen in primary care than in any other setting, and health center clients have greater behavioral health needs than typical primary care patients. Most health centers needed additional behavioral health services in 2010, and this need will be magnified to serve 40 million patients. Further testing of these workforce models are needed, but the degree of current underservice suggests that we cannot wait to move on closing the gap.

Development of integrated mental health care: critical workforce competencies

In integrated care, a person will have his or her medical and behavioral health needs addressed within one health care system. Support for integrated models has grown with the increasing awareness of how the medical comorbidities of individuals with serious mental illness contribute to their morbidity and mortality, the prevalence of mental health problems in the general population, and the mental health issues among those with chronic medical problems. The enactment of effective integrated care will demand developing clinicians who are trained to work with mental health needs at various levels of intensity, who are capable of addressing complex comorbidities, and who operate from a person-centered approach to care. In this light we argue that given their unique skill set and clinical training, Psychiatric-Mental Health Advanced Practice Nurses could play a critical role in integrated care and present policy recommendations which support the development of the Psychiatric-Mental Health Advanced Practice Nurses role in such models.