Emergency Removal of Supervision Requirements for Psychiatric Mental Health Nurse Practitioners: A Mixed-Methods Survey

The sudden high demand for mental health care after the onset of the COVID-19 pandemic (1–3) worsened a long-standing shortage of psychiatric providers in the United States (4). In response, the federal government issued several provisional policies to maximize the workforce by expanding telehealth services and allowing providers to practice and prescribe across state lines (5, 6). In addition, 22 state governors temporarily waived physician supervision for nurse practitioners (NPs) (7). This sudden change in NP scope of practice was unprecedented, especially in states such as Massachusetts, where NPs were previously regulated by restrictive laws. We surveyed NPs in Massachusetts to investigate how the emergency waivers affected NP care and found that psychiatric mental health NPs (PMHNPs) were significantly more affected by the waivers than were other types of NPs (8).

Despite well-documented evidence that NPs provide high-quality (9–11) and cost-effective care (12–14), restrictive scope-of-practice laws in 24 states prevent NPs from practicing to the full extent of their license and training (15). Although these laws intend to protect the public, they do not improve quality of care (16, 17) but rather reduce access to both general medical and mental health care, especially within high-risk communities (18–21). In the context of a worsening mental health crisis, understanding why scope-of-practice restrictions differentially affect PMHNPs may help inform policies to improve access to mental health care. The purpose of the survey conducted in this study was to understand the underlying drivers behind the high sensitivity of PMHNPs to the scope-of-practice change at the onset of the COVID-19 pandemic in Massachusetts.

Methods

We conducted a mixed-methods descriptive analysis of a Web-based survey of Massachusetts NPs conducted from May 8 to June 15, 2020, a period of peak COVID-19 hospitalizations in the state (22). We emailed survey invitations to the electronic mailing list of the Massachusetts Coalition of Nurse Practitioners, which includes both members and nonmembers. The landing page of the Qualtrics survey stated study eligibility criteria (clinically active NPs in March 2020) and informed consent, along with details about survey length (5 minutes), respondent anonymity, and data security. Four invitations were e-mailed over a 5-week period, with no financial or other incentive to participate. Participants provided responses anonymously, but some voluntarily provided e-mail addresses to participate in follow-up surveys.

The survey consisted of 10 closed-ended questions related to NP specialty, clinical setting, changes in employment, working hours during the pandemic, and organizational supervision policies (8). To examine the effect of waived supervision on clinical work, we asked, “Do you believe the waiver of supervision requirements has enabled you to improve your clinical work?” In addition, three open-ended questions (“Has your clinical work changed as a result of the temporary waiver of supervision requirements? If so, please explain”; “Does your employer impose supervision requirements different from state requirements? If so, please explain”; and “Is there anything else you would like to tell us about the impact of COVID-19 on your clinical work?”) focused on understanding NPs’ perceptions of care delivery related to the temporarily waived supervision. Given the unprecedented clinical context of the public health emergency, these questions elicited comments on a broad range of topics, including telehealth, autonomy, and changing patient needs (23).

The quantitative data were analyzed with Fisher’s exact test to examine the strength of associations between PMHNP certification and other variables, by using all other NPs as a comparison group. We used inductive content analysis to identify themes in the open-ended responses from PMHNPs. A team of three researchers (two NPs, M.O.R.-J. and Victor Petreca, D.N.P., Ph.D., and one non-NP, J.P.) independently read and coded responses. The team met to discuss meaning units, condense them into categories, and identify core themes. We established trustworthiness of the data by using credibility, transferability, dependability, and confirmability. Credibility was ensured by the full team debriefing and reaching a consensus on themes. Transferability was accomplished by providing a rich description of the themes, such that others could relate to them. To ensure dependability, we provided a step-by-step study description, enabling replicability. Confirmability was achieved by the non-NP review categories identified by the NPs to help ensure that the themes reflected the data and not personal experience. This study was approved by the Boston College Institutional Review Board.

Results

Of the 958 NPs receiving the survey invitation, 413 consented and 389 were eligible, resulting in a response rate of 41%. A subset of NPs (N=26, 7%) held psychiatric mental health certifications, whereas most held certifications in family (N=157, 40%), adult-gerontology (N=127, 33%), acute care (N=28, 7%), or other (N=51, 13%). These proportions reflected the composition of NPs nationally (24).

Quantitative Results

Table 1 shows a comparison of the clinical settings of PMHNPs with those of all other types of NPs. During March–May 2020, fewer PMHNPs than other NPs worked in ambulatory care (PMHNPs, 15% vs. non-PMHNPs, 50%). Table 2 allows comparison of PMHNPs and other NPs based on four key work-related variables. PMHNPs were significantly more likely than other NPs to work in a telehealth setting (42% vs. 11%, p<0.001), to spend more time working during the initial surge (50% vs. 26%, p<0.05), and to believe that the waiver improved clinical work (52% vs. 25%, p=0.003).

Qualitative Results

Four themes were identified through inductive content analysis of 18 PMHNPs who opted to provide comments prompted by the open-ended questions. These themes include the following: supervision waiver reduced burden, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet high demand for care.

Supervision waiver reduced burden.

The first theme, described by 44% (N=8 of 18) of the PMHNPs who provided comments, captured how the supervision waiver reduced burden for PMHNPs by streamlining care, alleviating the need to find a supervising psychiatrist in the middle of a shortage, and minimizing PMHNP migration.

First, many respondents believed that the reduction of administrative or regulatory burden streamlined their care. Some described no longer needing to “inform supervising physicians when starting stimulants,” whereas others conveyed a more global sense of autonomy and the ability to practice “without restriction.” Some felt that this reduction of administrative burden increased the timeliness of their care: “I am free to make decisions. I am faster to respond to emergencies. My PATIENTS ARE DOING BETTER.” For this PMHNP, more efficient care meant better patient outcomes.

Second, there was a sense of relief that PMHNPs no longer needed to maintain a supervisor amid a shrinking pool of older psychiatrists, who were particularly vulnerable to COVID-19 infection. This sentiment was best captured by this respondent:

For this respondent, the waiver ensured that PMHNPs’ ability to care for their patients would not be threatened by the fragility of the aging workforce of psychiatrists. This tension was long standing and existed before the pandemic, as conveyed by this respondent:

This comment highlights the sense of the precarious position that PMHNPs held before the waiver, because they were dependent on deteriorating workforce resources over which they had little control.

Last, some respondents felt that the waiver minimized the likelihood of PMHNPs’ going to neighboring states with full practice authority. For example, one PMHNP commented, “I have lost many colleagues due to relocation because of the MMA’s [Massachusetts Medical Association’s] strict hold on Massachusetts legislators.” This PMHNP equated the persistent supervision requirements with the political power of organized medicine. However, some PMHNPs were concerned about how continued restrictions would further exacerbate a shortage: “I have 3 NPs that work for me and more [who] want to join the practice. If this change is not permanent, they will go to [New Hampshire] or [Rhode Island].” This comment highlights that PMHNPs have many jobs to choose from in New England, and practice restrictions were a deterrent to stay in state.

Collaboration and mentorship models persisted.

Another theme that emerged from the qualitative data was the continuation of informal collaboration despite the lifted supervision requirement, described by 17% (N=3 of 18) of respondents. PMHNPs continued to consult with NP and physician colleagues alike. There was a strong sense that meaningful models of collegial mentorship were well established before the pandemic and were more valuable than state-mandated supervision. This sentiment was captured by the following comment:

This PMHNP expressed appreciation for as-needed consultations with peers but saw state-mandated supervision as unnecessary. This opinion was not unique to less experienced clinicians but was also prevalent among veteran PMHNPs. For example, this PMHNP commented:

Some PMHNPs described a willingness to mentor less experienced colleagues, such as this PMHNP: “If someone like me (a seasoned provider) could supervise new clinicians, we could reinforce our available mental health clinicians.” This respondent saw the authorization of experienced NPs to serve as collaborators for new NPs as an opportunity to grow the psychiatric workforce within a context of mentorship and alleviate the mental health care crisis.

The pandemic exacerbated the already high demand for psychiatric care.

Another prominent theme was the high demand for psychiatric care during the COVID-19 surge, described by 56% (N=10 of 18) of the respondents. This demand was described as an increase in both patient acuity and amount of visits, exemplified by comments such as “My workload has dramatically increased” and “Late cancelations and no-shows are down by about 85%.” Respondents suggested that demand was driven by both maintenance care for previous patients and establishing care for new patients.

This acute surge in demand, however, occurred amid a chronic shortage of care. This was described by one PMHNP:

This respondent described the chronic unmet need for mental health care and expressed concern about the increased demand during and after the pandemic.

Telehealth helped meet the high demand for care.

The valuable role of telehealth in meeting the increased demand for mental health care was evident in the comments of 44% (N=8 of 18) of respondents. Many PMHNPs related how telehealth ensured mental health care maintenance for established patients when the in-person setting was inaccessible. Some remarked that the transition of in-person psychiatric care to telehealth was surprisingly seamless, even among those not well versed in technology. Respondents also had a sense that requiring in-person care for psychiatric patients was a barrier to high-quality care during the pandemic, especially for patients lacking executive functioning or with acute mental illness. This PMHNP explained it well:

Other PMHNPs also described how telehealth enabled patient-centered care by allowing close follow-up without triggering anxiety related to traveling for appointments. Although most respondents appreciated telehealth, a few reported some downsides, such as this PMHNP: “Doing telehealth is draining in ways that an in-person visit is not—exhausting at the end of the day seeing equal numbers of patients as if I were going into hospital.” Others were concerned with a lack of access for patients with lower digital literacy or those requiring an in-person setting.

Discussion

We conducted a survey of 389 Massachusetts NPs during the height of the first COVID-19 surge. We found that, compared with other NP specialties, PMHNPs experienced both higher demand for their care and a greater impact of the scope-of-practice change on their clinical work, which were both likely facilitated by the higher uptake of telehealth by PMHNPs. Our qualitative analysis of 18 PMHNPs’ responses to the open-ended questions revealed four major themes: the Massachusetts supervision waiver in response to the COVID-19 pandemic emergency reduced burden on PMHNPs, collaboration and mentorship models persisted, the pandemic exacerbated the already high demand for psychiatric care, and telehealth helped meet the high demand for such care.

Temporary State Scope-of-Practice Change

On the basis of the responses of a small group of PMHNPs, our findings suggest that constraints imposed by the psychiatrist shortage may be the underlying driver behind PMHNPs’ high sensitivity to scope-of-practice changes in the wake of the COVID-19 emergency, relative to other NPs. These results are consistent with those of other studies that point to PMHNPs’ substantial challenges in finding and maintaining a supervising psychiatrist (25). Unlike PMHNPs, most other NPs did not face the same obstacles in maintaining supervision because of a larger and younger supply of physicians in other clinical areas. These challenges were further exacerbated by the pandemic. Whereas other types of NPs experienced a drop in patient volume (26), PMHNPs experienced a sharp rise in demand for their care, and the scope-of-practice change immediately lifted their burden of finding a willing psychiatrist supervisor.

Massachusetts moved to permanently adopt full practice authority for NPs in January 2021, and support has grown for the modernization of NP scope-of-practice laws to increase access to care in the remaining 50% of states with restrictive laws (27–31). Nationwide, the PMHNP workforce is growing and now comprises 31% of the total psychiatric provider-to-population ratio (32). In 15 states, PMHNPs make up over a third of all psychiatric providers, and PMHNPs generally are more likely to practice in states with fewer restrictions (32, 33). Modernizing scope-of-practice laws will be particularly influential in restricted practice states with high levels of unmet mental health needs (e.g., in Florida, Missouri, North Carolina, and Tennessee) that already rely heavily on PMHNPs (34).

Nonmandated Models of Collaboration

Our results indicate that eliminating psychiatrist supervision does not change meaningful models of PMHNP collaboration, which are well established and, possibly, more valuable than mandated psychiatrist supervision. For many PMHNPs in our study, regulated supervision before the pandemic was strictly a bureaucratic requirement and inconsequential to their practice, echoing other results suggesting that supervision of NPs is much less frequent than stipulated by regulations (25). The unregulated interprofessional collaboration that occurs naturally between peers and within teams is highly valued by both NPs and physicians (25, 35). Whereas regulating collaboration among experienced clinicians serves little purpose, ensuring new clinician access to a robust supply of mentors is critical and could be facilitated by a range of stakeholders (e.g., professional organizations, state boards of nursing, and public health departments).

At the time of this writing, 15 states authorize full practice authority at the point of licensure, whereas 10 states require that new NPs collaborate with experienced providers during a stipulated period (usually 2 years). As of January 2021, Massachusetts joined seven other states that authorize NPs to serve as collaborators during this transition-to-practice period, avoiding the limits of the shortage of psychiatrists. Adopting similar provisions in other restricted states is another opportunity to reduce practice barriers and improve access to mental health care, albeit not as optimal as organic, nonmandated collaboration.

Telehealth Facilitated a Demand for Psychiatric Care During the Pandemic

The increased demand for mental health care at the onset of the COVID-19 pandemic was both met and alleviated by telehealth services. Given the compatibility of telehealth and mental health care (36, 37), PMHNPs used telehealth more than did other types of NPs. These results are consistent with nationwide trends during the initial stage of the pandemic, when patient volume was low in most clinical areas, but stable within psychiatry, likely because of its high telehealth adoption rate (26). Among all the specialties, mental health saw the largest increase in telehealth use in the Medicare program in 2020, stabilizing far above prepandemic levels; by the end of 2020, telehealth psychiatric visits were as common as in-person visits (38).

Overall, it is difficult to untangle the effects of telehealth expansion from those of the scope-of-practice changes on the experience of PMHNPs during the onset of the COVID-19 pandemic. However, for many PMHNPs, expanded telehealth reimbursement and the waiver of psychiatrist supervision appear to have created a net effect of improving access for their patients to much-needed psychiatric care. Although it remains to be seen whether the benefits of telehealth (39–41) outweigh its potential costs (26, 41–44), there are signs that it is receiving broad support from policy makers. As more permanent adoption of telehealth takes shape (45, 46), it will be critical to continue examining how telehealth expansion interacts with scope-of-practice laws, especially among PMHNPs.

Together, telehealth expansion and persistent NP practice barriers could conspire to exacerbate access disparities in underserved communities. Rural and high-poverty counties experience both a lower uptake of telehealth (26, 47) and intensified psychiatrist shortages (48). Because of the limited supply of psychiatrists, PMHNPs in underserved areas face greater regulatory barriers (e.g., paying higher physician supervision fees and continued supervision), thereby limiting PMHNPs’ capacity to improve access to care in high-need areas (19, 25, 49). Modernizing NP scope-of-practice restrictions and enabling clinicians to provide telehealth across state lines will be most effective in underserved areas.

Limitations

These findings should be interpreted in the context of several limitations. First, the sample was drawn from a list of past and current members of an advocacy organization for NPs. PMHNPs belonging to this organization may be more experienced and potentially more politically engaged than PMHNPs who do not belong to this group. Further research targeting NPs who are not members of advocacy groups would be an important validation step. In addition, this was a brief survey designed to minimize respondent burden. Consequently, the survey did not capture several important factors that may affect a PMHNP’s perception of the pandemic and scope-of-practice change, including practice type and characteristics, region, level of NP experience, and degree type (doctorate versus master’s degree), among others. These are important contextual factors to consider in future research. Last, our results are generalizable to states with persistent NP practice restrictions and particularly relevant to those acutely affected by the psychiatric workforce shortages.

Conclusions

The findings of this mixed-methods study suggest that scope-of-practice laws and changes in telehealth rules affect specific types of NPs differently. The complex interactions among workforce, regulation, and payment rules may disproportionately affect the delivery of mental health services relative to other types of care. As policy makers debate the future of telehealth, these complexities should not be overlooked. Modernizing NP scope-of-practice laws, with or without telehealth expansion, promises to increase access to mental health care, especially for at-risk populations.