by James M. Stevenson, MD, Chief Medical Officer, Signet Health

The growing need for behavioral health services coupled with the great demand for psychiatrists is forcing many hospitals to rethink how they utilize their staff. It is also forcing overworked psychiatrists to open up to new ways of working, including incorporating Psychiatric Mental Health Nurse Practitioners (PMHNPs).

Although often overlooked in the staffing model of inpatient psychiatric units, PMHNPs are highly educated individuals who have the skillset to diagnose mental illness and prescribe medication and bring exceptional value to a team.

PMHNPs are already helping to fill the gap in the outpatient rural market.  The proportion of all mental health prescriber visits provided by PMHNPs increased from 12.5 percent to 29.8 percent in 2011–19, exceeding 50 percent in rural, full-scope-of-practice regions.[1]

On the inpatient side, psychiatrists have more demands placed on them because of all the regulatory and reimbursement requirements. A skilled PMHNP can unburden the psychiatrist of many professional tasks that don’t require a psychiatrist’ level of skill. 

Additionally, the psychiatrist benefits by pairing themselves with a PMHNP because they can extend their practice and the care they are rendering.  For example, a hospital can run a 20-bed unit very efficiently and effectively with one psychiatrist and a PMHNP. This model is more cost effective.  

The concept of nurse extenders is not new, however, how well they work on an inpatient unit really depends on how the psychiatrist incorporates them into his or her daily routine.

The PMHNP can be utilized in the call loop, with backup from a psychiatrist. They can respond to calls that come in the middle of the night, triage and handle entrance into the units with orders that can be reviewed the first thing the next morning by the psychiatrist and signed off on then.

On many inpatient units, a PMHNP can also:

• Provide individual, group, and family therapy
• Provide medication management in collaboration with a psychiatrist
• Coordinate multidisciplinary services for clients with complex psychiatric problems
• Serve as a psychiatric consultant to the Emergency Department

The fact is, PMHNPs can typically do all the tasks of a psychiatrist and currently are allowed to in 39 states where there is not a restricted practice environment for Nurse Practitioners.

This model does not sacrifice the level of care and in the eyes of patients it may actually improve. Nurse Practitioners in general are receiving high marks in patient satisfaction and communications skills across several national surveys. These skills transfer well to psychiatric care as it has become very team oriented. The more effective the team, the more effective the care and the better the outcomes. For this pairing to be successful, the psychiatrist and the PMHNP need to have a solid relationship that filters down throughout the unit.  All team members need to be encouraged to speak openly about their patient observations and share that information in daily morning team meetings. The psychiatrist needs to listen to the nurses’ report and ask questions regarding specific interactions as the nurses and mental health technicians are on the floors and in the patients’ rooms. For example, they can help fill in the gaps of what might have been an irritant or a challenge in the life of “Mr. Brown” that causes terrible bouts of depression or manic behaviors. The PMHNP can play a very important role in fostering an environment of open communication.

For inpatient programs considering pairing a psychiatrist and PMHNP

When determining if adding a PMHNP to your behavioral health service line is the right move, it is first important to get a sense of what the patient demand is, how well and efficient the unit runs, the perception of the entire nursing staff and the need for outpatient provider coverage.  The staff need to be able to share the degree to which they’re able to practice their professions and feel good about what they’re able to provide for the patients. After this assessment, it is important to talk to the psychiatrist to determine how they currently run their practice and if they believe it can be more efficient.

The bottom line is psychiatrists need to learn to work with PMHNPs. The nursing profession has evolved enormously in the last 20 years and, recognizing this need, teaching hospitals have placed a large focus on developing specialty programming for psychiatry. Regardless of the healthcare system they are in, most psychiatrists are so busy they don’t have time to adequately handle all the patients they are trying to access throughout the day. They need help and from both a quality of care and business perspective, it makes sense to incorporate PMHNPs in a successful practice.

[1] Cai A, Mehrotra A, Germack HD, Busch AB, Huskamp HA, Barnett ML. Trends in mental health care delivery by psychiatrists and nurse practitioners in Medicare, 2011-2019: study examines trends in mental health care delivery by psychiatrists and nurse practitioners in Medicare. Health Aff. 2022;41(9):1222-1230. https://doi.org/10.1377/hlthaff.2022.00289