Discuss this article at www.facebook.com/CurrentPsychiatry
Psychiatrists who are accustomed to working with “med/surg” or psychiatric nurses may be less familiar with how to collaborate with more specialized psychiatric-mental health nurse practitioners (PMHNPs). These clinicians play an important role in delivering mental health services, which is likely to continue because of the physician shortage in the United States1 and increasing mental health care needs from passage of the Affordable Health Care Act and the Mental Health Parity Act.2 These specialty trained, master’s level nurses work with psychiatrists in outpatient clinics, hospital consultation and liaison services, psychiatric emergency services, inpatient units, and geropsychiatric consultation.3-5 PMHNPs can fill gaps of coverage in underserved areas, supplement and complement busy and overburdened psychiatrists, and add an important dimension of holistic care.
This article reviews issues related to a successful psychiatrist-PMHNP collaboration, including:
- PMHNP’s training and scope of practice
- their skill and competency development in inpatient and outpatient settings
- the principles and dynamics of collaboration, hindrances to cooperation, and keys to relationship-building for PMHNPs and psychiatrists.
Rigorous requirements
PMHNPs enroll in an accredited graduate nursing program that takes 16 to 24 months to complete and builds on the competencies of their undergraduate nursing education and clinical experience. All programs meet standards set by national nursing accrediting agencies. The typical graduate-level curriculum for a PMHNP includes core bio-behavioral theory, research courses, advanced physiology and pathophysiology, advanced physical and psychiatric health assessment, pharmacologic and nonpharmacologic interventions, and managing health care delivery systems. For graduation and certification, PMHNPs must complete 500 supervised clinical hours focused on psychiatric and mental health care.
- comprehensive psychiatric evaluation
- formulation of a differential diagnosis
- ordering and interpreting diagnostic tests
- prescribing pharmacologic agents
- conducting individual, couple, group, or family psychotherapy using evidence-based approaches.
PMHNPs also are responsible for recognizing the limits of their knowledge and experience, planning for situations beyond their expertise, and providing appropriate referral to other health care providers when indicated.8
Successful collaborative practice requires a clear definition and understanding of roles.9 This is particularly important for collaborating psychiatrists and PMHNPs because there has been confusion among physicians and the general public related to the nurse practitioner’s role. Psychiatrists who work with PMHNPs need to be familiar with state regulations that govern levels of physician supervision and prescriptive authority for nurse practitioners. Eleven states and the District of Columbia allow nurse practitioners to prescribe independently, including controlled substances. Most states require physician collaboration for prescribing medications, but the language can be ambiguous, with restrictions on certain formularies or drug schedules—eg, Michigan nurse practitioners may prescribe schedule II through V controlled substances, but schedule II medications are limited to nurse practitioners who work in hospitals, surgical outpatient settings, or hospices.10
Competencies and development
New PMHNPs see patients and prescribe medication, but their work needs close supervision. Postgraduate clinical experience combined with supervision gradually allows the PMHNP greater independence. A PMHNP who provides care in a busy outpatient clinic, inpatient unit, or psychiatric emergency department is likely to master the treatment philosophy and ancillary competencies related to that particular clinical site—including favored pharmacologic approaches, electronic documentation and ordering functions, and admission and discharge facilitation—at a level exceeding that of psychiatric residents, who rotate on and off a service as part of their training.
It’s helpful for new PMHNPs to have a time frame for their development over several years. The Table11 outlines general graded competency areas PMHNPs may focus on in their development. See this article at CurrentPsychiatry.com for Tables that provide examples of detailed competencies for third-year PMHNPs in inpatient and outpatient settings.
Table
PMHNP development: General graded competency areas
| Psychiatric evaluation and diagnosis |
| Psychiatric treatments, including medications and psychotherapies |
| Maintenance of the therapeutic alliance, including monitoring the PMHNP’s emotional responses to patients |
| Participation in an interdisciplinary team |
| Understanding comorbid medical conditions, integrating laboratory and other tests into the treatment plan, and recognizing the need for consultation with the medical team |
| Documentation, such as initial evaluations, progress notes, and discharge summaries |
| Assessment for suicide and violence potential |
| Teaching |
| Patient and family psychoeducation |
| Use of feedback and supervision |
| PMHNP: psychiatric-mental health nurse practitioner Source: Reference 11 |