The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use, including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

×
Case Studies in Public-Sector LeadershipFull Access

Integrating Psychiatric Nurse Practitioners Into Psychiatric Practice Settings

Introduction by the column editors: This column is based on the use of an electronic mailing list (e-list) to generate a collaborative problem-solving process. For this column, Dr. Theccanat put together responses from himself and other e-list alumni of the Columbia University Public Psychiatry Fellowship to questions posed by Vanessa Bobb, M.D., who works at a free-standing licensed mental health clinic and for the first time wanted to hire a part-time psychiatric nurse practitioner to see adult clients. Dr. Bobb wanted to know what the typical salaries are for psychiatric nurse practitioners and the typical number of medication visits that they schedule per day. She also sought advice on places to advertise and to post announcements. Readers are invited to submit suggestions for e-list discussions of management problems to column editor Jules Ranz, M.D. (e-mail: ).

Advanced practice nurses (APNs), also known as psychiatric nurse practitioners, contribute significantly to contemporary mental health care in partnership with psychiatrists. Many psychiatric hospitals, agencies, and programs are integrating APNs into their psychiatric practice, and some people might be concerned about how to ensure the continuation of high-quality care to mental health consumers. A report by the Substance Abuse and Mental Health Services Administration described the severity of the shortage of mental health professionals, both prescribers and nonprescribers, and its effect on millions of people (1). A shortage of psychiatrists and an increasing need for mental health care have both been noted, and APNs have the potential to bridge this widening gap (2).

The American Psychiatric Nurses Association recognizes and promotes the integration of APNs with advanced skills in psychiatry into a variety of psychiatric practice settings. After an individual receives a graduate degree, the curriculum of the average APN program lasts approximately 16 to 24 months and includes 500 supervised clinical hours. By comparison, psychiatrists who provide services to adults require 48 to 60 months of supervised clinical hours and child psychiatrists require 60 to 72 months (2,3). A 2010 Carnegie Foundation report called for decreasing the time spent in medical education by standardizing learning outcomes and general competencies to provide greater options for individualized learning while maintaining high standards (4). Psychiatric nurse practitioners are prepared to uphold their clinical role in delivering mental health care yet are required to have a collaborative agreement with psychiatrists by most states’ regulatory standards. The newly trained APN also requires a degree of mentoring from either a psychiatrist or a seasoned APN. The responsibilities of the APN are established through review and evaluation with this mentor. In collaboration with the medical practitioner, these responsibilities include assessment and diagnosis of psychiatric disorders in complex psychiatric presentations, prescription of medications appropriate for treatment of mental disorders, and familiarity with all current medical terminology and with reimbursement and coding. The APN must perform these duties while maintaining the unique characteristics of humanism and the broad holistic view of the individual and his or her care needs that define nursing practice (5).

Professional Partnerships: Benefits and Limitations

Both the consumer and the medical institution derive many benefits from integration of APNs into psychiatric practice settings. Studies measuring consumer satisfaction with mental health services have reported that consumers rate their experience with an APN equal to their experience with a physician. Qualitative studies have shown that consumers report being able to relate more easily to an APN than to a psychiatrist. In these studies, most consumers indicated feeling less intimidated because the characteristics of their relationships with the APN were less formal than their relationships with the medical practitioner. With a heightened comfort level, consumers perceived having more time to speak with the APN regarding symptoms and concerns (6). A systematic review of 37 studies published between 1990 and 2008 concluded that APNs provide effective and high-quality patient care and that clinical nurse specialists in acute care settings can reduce the length of stay and the cost of care for hospitalized patients (7). Economic advantages to hospitals and psychiatric agencies and organizations include reduced overall organizational costs based on salaries and other factors, which in turn allow more patients to be served. APNs fill a widening gap, and employing them can address the difficulties of hiring psychiatrists in the current market, where there is a growing shortage of psychiatrists (6).

Along with these benefits are also some limitations and potential conflicts that must be considered when introducing APNs into psychiatric practice settings. Biases and entrenched, outdated policies, practices, and paradigms exist within the medical community, which may impede an easy transition and may prevent the APN from being able to function and from being fully supported in fulfilling necessary tasks. Consumer bias can also be a complicating factor. Studies show that consumers are concerned that they may be receiving different and potentially substandard care when treated by an APN (6). Any institution hiring an APN needs to be fully aware of any local or state legislation or regulations regarding funding or standards of practice that may conflict with the use of APNs as described above.

When Vanessa Bobb, M.D., decided to hire a part-time psychiatric nurse practitioner to see adult clients at the free-standing licensed mental health clinic where she worked, she had several questions for the Columbia University Public Psychiatry Fellowship alumni e-list, and benefits and limitations were among the issues addressed in the e-list discussion. It was noted that Medicare reimbursement for services rendered by an APN is 15% less than for services provided by a psychiatrist. Other e-list responses addressed levels of responsibility, which may vary among states and institutions. New Jersey APNs, unlike psychiatrists, cannot perform initial evaluations and create treatment plans for involuntarily hospitalized patients, and such patients must be seen on alternate days by a physician. In New York, APNs cannot sign applications for case management, and they cannot evaluate or sign off on a case after a therapeutic hold has been established. The discussion also indicated discrepancies regarding procedures of the Social Security Administration, which has refused in some cases to accept applications for disability signed by an APN.

An e-list respondent reported that her clinic had difficulty finding a secure resource for well-trained APNs. Rather than expend time and effort for on-the-job training, the clinic concluded that the needs of the populations it serves are better met by psychiatrists. The respondent felt that psychiatrists have greater training and expertise and are generally better suited to directly care for clients who have complex psychiatric and medical comorbidities.

As each of these discussion points makes clear, effective integration of an APN into a behavioral health practice requires a degree of careful and goal-directed research, from agency policy, norms, and culture to larger community, regional, and national policies and legislation.

Practical Considerations in Hiring

The strongest responses in the e-list discussion were to Dr. Bobb’s inquiries about the practical considerations of integrating an APN into a behavioral health practice. These questions included how best to advertise the position, norms regarding salaries and hours, logistics of scheduling, expectations and requirements in the psychiatrist-APN collaboration, and hosting APN student interns. In reference to advertising, it was suggested that Indeed.com, an employment-related meta-search engine for job listings, was a good source for targeting APNs. Other respondents described using fee-based recruiters, whose fees range from $15,000 to $30,000 per hire. Although responses indicated some variations in APN salaries, e-list respondents agreed that the pay range was well above the normal to high range for nursing salaries but lower than the range for physicians. Hours offered to APNs ranged from full-time to part-time and depended on the clinic’s settings and needs. Most APNs are looking for full-time hours.

Paramount to the successful assimilation of an APN is the necessity for clarity and precision in designing an effective and efficient system that clearly outlines all aspects of responsibility and expectations for the APN and the overseeing and supportive role of the collaborating psychiatrist. One e-list respondent offered a collaborative practice agreement that outlined the scope of practice, practice protocols, consultation with the physician, record reviews, adherence to accepted standards of medical practice, procedures for resolving disagreements, and the frequency of documentation and review of clinical progress. Finally, respondents reported a growing interest in supporting APN students through internships via partnerships with nursing programs.

An APN colleague, consulted for this column, stated that the need for a formal collaborating agreement is slowly being removed, state by state. In 2014, the State of New York established that the formal collaborating agreement is not required after the APN has more than 3,600 hours of qualifying nurse practitioner experience. This change in policy, according to this informant, is driven by the shortage of mental health practitioners but also by the similar patient outcomes that are achieved by physicians and APNs.

Conclusions

Integrating APNs into psychiatric practice can address a number of mental health care needs formerly met primarily by the psychiatrist alone. There are clear benefits to introducing APNs to work in collaboration with psychiatrists, as well as limitations. Although the APN can contribute a new dimension to the interaction with the mental health consumer, it is imperative to understand the complexity of the relationship between the psychiatrist, the APN, and the rest of the team.

Dr. Theccanat is with the Department of Psychiatry, Monmouth Medical Center, Long Branch, New Jersey (e-mail: ). Jules M. Ranz, M.D., Susan M. Deakins, M.D., and Stephanie Le Melle, M.D., are editors of this column.

The author reports no financial relationships with commercial interests.

References

1 Report to Congress on the Nation’s Substance Abuse and Mental Health Workforce Issues. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2013Google Scholar

2 Casher MI, Kuebler J, Bastida M, et al.: How to collaborate effectively with psychiatric nurse practitioners. Current Psychiatry 11(11): 49–54, 2012Google Scholar

3 About Advanced Practice Psychiatric Mental Health Nurses. Falls Church, Va, American Psychiatric Nurses Association. Available at www.apna.org/i4a/pages/index.cfm?pageID=3857Google Scholar

4 Irby DM, Cooke M, O’Brien BC: Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine 85:220–227, 2010Crossref, MedlineGoogle Scholar

5 Flaskerud JH: DSM-5: implications for mental health nursing education. Issues in Mental Health Nursing 33:568–576, 2012Crossref, MedlineGoogle Scholar

6 Wortans J, Happell B, Johnstone H: The role of the nurse practitioner in psychiatric/mental health nursing: exploring consumer satisfaction. Journal of Psychiatric and Mental Health Nursing 13:78–84, 2006Crossref, MedlineGoogle Scholar

7 Newhouse RP, Stanik-Hutt J, White KM, et al.: Advanced practice nurse outcomes 1990–2008: a systematic review. Nursing Economics 29:230–250, 2011MedlineGoogle Scholar