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Evidence-Based Reviews


How to collaborate effectively with psychiatric nurse practitioners

Understanding these clinicians’ training and skills can improve patient care

Vol. 11, No. 11 / November 2012

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.

Each certified PMHNP must pass a national certification examination and obtain a license to practice as an advanced practice nurse (APN). To maintain certification, every 5 years PMHNPs must complete 75 to 150 continuing education credits and accrue 1,000 practice hours. The Psychiatric Mental Health Nursing Scope and Practice Standards developed by the American Nurses Association in conjunction with the American Psychiatric Nurses Association and the International Society of Psychiatric-Mental Health Nurses includes the following competencies:6

  • 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.

In May 2012, the Centers for Medicare and Medicaid Services finalized rules that affirmed an equal role for physicians and nurse practitioners in hospital medical staff affairs, and allowed nurse practitioners to work to the full extent of their educational preparation.7

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

Table 1

Competencies for third-year PMHNPs in an outpatient clinic

Recognize clinical presentations of complex psychiatric disorders, variants, and comorbidities

Firm knowledge of diagnostic criteria, and skills for independent comprehensive assessment and diagnosis

Firm knowledge of evidence-based outpatient treatments for disorders, with mastery of ≥1 nonpharmacologic modality in addition to prescribing and managing medications

Use and provide feedback in comprehensive case formulations and treatment plans

Assist in clinical education of trainees in psychiatric nursing, social work, psychiatric residency, and psychology

Participate and collaborate in educational events and initiatives

Knowledge of internal and external health system and resources, and facilitating patient access to these networks

Incorporate mental health and behavioral and psychiatric nursing research into patient care

PMHNP: psychiatric-mental health nurse practitioner

Table 2

Competencies for third-year PMHNPs on an inpatient psychiatric unit

Refinement of assessment section in evaluations, progress notes, and discharge summaries

Understanding indications for neuropsychological testing, and integrating findings into the treatment plan

Assessment of readiness for discharge in patients with a history of suicidality or violence

Developing a sophisticated and detailed discharge or follow-up plan

Understanding treatment resistance in mood and psychotic disorders, and implementing treatment

More detailed knowledge of types of illness treated on an inpatient unit

Ability to orient and train PMHNPs and other inpatient unit trainees

Ability to gather and use articles and other literature pertaining to inpatient care

Increasing competence in short-term, crisis-based therapeutic techniques, including familiarity with DBT, CBT, and IPT

Understanding family systems and impact on patient care

CBT: cognitive-behavioral therapy; DBT: dialectical behavior therapy; IPT: interpersonal therapy; PMHNP: psychiatric-mental health nurse practitioner

Principles of practice

Studies have demonstrated the importance of understanding how to effectively implement collaborative care across medical disciplines.12 See the Box12 for a discussion of 3 key determinants for successful clinical collaborations.

Box

Successful clinical collaborations: 3 determinants

San Martín-Rodríguez et al12 recognized 3 key factors that may help develop successful collaborative clinical relationships.

Interactional factors include a mutual willingness to collaborate, a commitment to collaborate, a belief in the benefits of collaborating, and sharing common objectives. Trust in the partnering clinician’s competency contributes to a successful collaboration. Strong communication skills—including the ability to convey what each clinician can contribute to achieving goals—also strengthens collaboration. Learning and understanding skills in conflict management and dialogue are key. Mutual respect also is essential.

Organizational factors include a shift from a traditional hierarchical structure to a more horizontal structure, and a work climate that supports openness, risk taking—ie, a willingness to disagree with a colleague if it is in a patient’s best interest or to develop a new and innovative method of providing care—integrity, and trust. Administrative structures and supports that convey the importance of collaboration also are key components of a strong collaborative environment. Teamwork and shared decision-making are important elements; teamwork should include time to discuss patient issues and develop strong interpersonal relationships. A commitment to professional development is another key factor.

Systemic factors include a social system that supports collegial relationships and professionalism that respects and accepts other professions. This includes decreased focus on protecting professional territory and increased recognition of overlaps among professions.

Enhancing collaboration

Psychiatrists who work with PMHNPs develop trust based on observing each PMHNP’s work, including their relationship with patients, ability to conceptualize a case and develop a treatment plan, and the skill with which they function within a team. The psychiatrist’s comfort level also is related to his or her awareness of the comprehensiveness of the PMHNP’s training and the competencies gained from clinical experience. Respect for the PMHNP’s educational and professional background is the foundation for what is often—at least in the collaborative relationship’s initial stages—a combined cooperative and supervisory relationship with the PMHNP. As such, the PMHNP gradually will absorb certain “intangibles” to supplement the training and work experiences that preceded his or her position. This may include assimilating the psychiatrist’s or clinic’s philosophy and treatment practice, including expertise in dealing with specialized psychiatric populations (eg, developmental disabilities, acute psychosis, or treatment-resistant depression).

As with any relationship, the individuals’ specific traits and ability to communicate and negotiate differences13 contribute to working well together. Ideally, in a psychiatrist-PMHNP relationship, both parties recognize “the need for independence and the desire for professional autonomy as well as…each other’s expertise and strength in the delivery of health care.”13 At the practical level, this may mean that the psychiatrist may note—and benefit from—factors such as a PMHNP’s particular ease with patients with borderline personality disorder, skill in managing patients with anorexia nervosa, or facility in educating families.

The patient’s comfort level

Collaborating PMHNPs and psychiatrists need to be prepared for a patient who expresses disappointment with being treated by a PMHNP or a preference to see “a doctor.” Psychiatrists who have not worked through their own ambivalence about the collaboration or who lack confidence in the PMHNP’s abilities may find themselves consciously or unconsciously aligning with the patient’s stance. They may neglect to explore the basis and meaning of the patient’s preference, which may be related to the patient’s lack of knowledge about the PMHNP’s role and training. The PMHNP who encounters such a patient has a more challenging task—namely, how to calmly address the patient’s concern while the patient is challenging the PMHNP’s competence. Both the PMHNP and psychiatrist need to be alert to the possibility of “splitting” in the treatment of axis II-disordered patients.

Studies of patient satisfaction have found that patients generally have favorable views of treatment received from nurse practitioners.14,15 These findings have been confirmed for PMHNPs.16,17

Barriers to collaboration

From the PMHNP perspective, barriers to a collaborative relationship include referring to PMHNPs by a less preferred term or title, instead of a nurse practitioner or APN, which can hinder the relationship. Although physician assistants and NPs have been grouped together under the term “mid-level providers,” the American Academy of Nurse Practitioners notes that this term suggests a lower level of care or service is being provided.18 “Physician extender” is another term that fails to recognize the PMHNP’s separate and unique role and the PMHNP’s view of their role as complementary to medicine, rather than an extension of a physician’s practice.

Another barrier is the psychiatrist’s lack of understanding regarding the PMHNP’s role. Because hospitals employ PMHNPs without providing psychiatrists formal direction explaining their role, background, or educational requirements, psychiatrists may ignore the PMHNP’s full potential. Sometimes, a psychiatrist may categorize an experienced PMHNP as a trainee rather than a highly skilled, trained professional. Although PMHNPs may gain knowledge and supervisory help from an attending psychiatrist, they have—unlike psychiatric residents—completed their formal training.

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