Stop me if you have heard this before, but there are not enough psychiatrists to meet the current demands of our population. Research indicates that as many as 45,000 additional psychiatrists are needed.1 Couple that with residency slots remaining stagnant over the past decade and the fact that 50% of psychiatrists are over age 55, and it is clear that psychiatrists alone will not meet this daunting need.1
The demand for more clinicians to treat patients with mental health problems creates a unique opportunity to integrate nurse practitioners and other multidisciplinary providers into psychiatric training and clinical practice. Psychiatric nurse practitioners (PNPs) are well positioned to extend the psychiatric workforce given their nursing/medical background and the specialized psychiatric training they receive in advanced practice programs. As the role of PNPs expands to meet mental health demands, psychiatrists need to take on a collaborative clinical educator role as the implementation of collaborative models increases.
As you begin to integrate PNPs into your practice or clinic, it is essential to first know the legal rules and regulations that can vary from state to state. According to the American Association of Nurse Practitioners’ most recent assessments, independent practice is allowed in 20 states and allows for nurse practitioners to practice under the guidance of the state nursing board.2 In the majority of states, however, PNPs have to work with a psychiatrist to provide care in a supervisory model, which varies from ratios of 3:1 and up to 7:1.
Note that all licensed nurse practitioners registered with the Drug Enforcement Administration can prescribe medications from any class of psychotropic medication, including controlled substances in 49 out of 50 states. Regardless of the state, however, collaboration between physicians and nurse practitioners is the standard of care and learning how to best to make the collaboration work is important.
In many public sector/underserved settings, the psychiatrist is no longer the front-line solo care provider and must collaborate and rely on the clinical judgment and experience of the treatment team, including primary care providers, nurse practitioners, therapists, nurses, and case managers.3 To perform in this setting, the psychiatrist must understand the strengths, weaknesses, roles, and expertise each provider brings to the team.4
Training and experience
All nurse practitioners begin as registered nurses, often working in mental health before going for training as a nurse practitioner. This training can be done as Master of Nursing or Doctorate. The differences between the 2 degrees revolve around research and amount of leadership, but the clinical experience and training are largely similar, with the same licensing for both after graduation. This clinical experience amounts to an average of 1000 to 1500 hours, compared with the 6000 hours for medical school plus residency.5 While some nurse practitioners do a year of residency for extra training after school, this is not mandatory.
When establishing a clinical relationship, it is important to understand the unique background and experience of the nurse practitioner you will be working with as new graduates will need more intensive supervision than the minimum ratio required. In fact, some states (eg, California) require closer supervision (from 2:1 to 4:1) during the first year in practice. As with physicians, nurse practitioners sit for their own boards and must maintain their certification and licensure.6 This requires them to pass their initial exam as well as 75 to 150 continuation education credits and 1000 practice hours every 5 years.
Dr. Malak is Assistant Clinical Professor and 3rd Year Residency Site Director in the department of psychiatry at the University of California, San Diego (UCSD); he is also Associate Director of the UCSD Community Psychiatry Fellowship. He reports no conflicts of interest concerning the subject matter of this article.
1. Kaas MJ, Beattie E. Geropsychiatric nursing practice in the United States: present trends and future directions. J Am Psychiatr Nurses Assoc. 2006; 12:142-155.
2. American Association of Nurse Practitioners. State Practice Environment. https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment. Accessed May 8, 2016.
3. Paré L, Maziade J, Pelletier F, et al. Training in interprofessional collaboration: pedagogic innovation in family medicine units. Can Fam Physician. 2012;58:e203-e209.
4. San Martín-Rodríguez L, Beaulieu M-D, D’Amour D, Ferrada-Videla M. The determinants of successful collaboration: a review of theoretical and empirical studies. J Interprof Care. 2005;19(suppl 1):132-147.
5. American Academy of Family Physicians. Education and Training: Family Physicians and Nurse Practitioners. http://www.aafp.org/dam/AAFP/documents/news/NP-Kit-FP-NP-UPDATED.pdf. Accessed May 8, 2016.
6. International Society of Psychiatric-Mental Health Nurses. Psychiatric Mental Health Nursing Scope & Standards: Draft Revision 2006. http://www.ispn-psych.org/docs/standards/scope-standards-draft.pdf. Accessed May 8, 2016.
7. Clarin OA. Strategies to overcome barriers to effective nurse practitioner and physician collaboration. J Nurse Practitioners. 2007;3:538-548.