Larry Malak, MD

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.

 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.

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’ 

, independent practice is allowed in 20 states and allows for nurse practitioners to practice under the guidance of the state nursing board.

 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.

 To perform in this setting, the psychiatrist must understand the strengths, weaknesses, roles, and expertise each provider brings to the team.

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 

 amounts to an average of 1000 to 1500 hours, compared with the 6000 hours for medical school plus residency.

 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 

 This requires them to pass their initial exam as well as 75 to 150 continuation education credits and 1000 practice hours every 5 years.

After establishing the level of experience and expertise of the nurse practitioner on your team, it is important to define a system for clinical care, collaboration, and supervision that will be used in your practice setting. While collaboration and communication are always part of the treatment team expectations, there are different ways to design your practice with a PNP.

Collaboration will be part of the solution to the workforce issue that leaves so many underserved patients without good mental health care

In one model, the nurse practitioner is primarily responsible for doing initial assessments with patients and then the follow-up is divided between the psychiatrist and the nurse practitioner. The advantage of this to a clinical care system is that it is more cost-effective for the PNP to be responsible for longer appointments. However, the psychiatrist should be available to communicate and collaborate with the nurse practitioner when issues arise in developing the initial treatment plan.

Another model in many clinical settings will have the psychiatrist do all the initial assessments and treatment plan development, while the nurse practitioner is responsible for continuity of the treatment plan through medication management visits. This allows the psychiatrist to set the lead and the tone for the treatment that will be carried out within the team setting. As problems or difficulties arise in the treatment, the PNP can consult with the psychiatrist or have the patient follow up with the psychiatrist to re-evaluate the treatment and adjust the plan as needed.

The final model has both the psychiatrist and the nurse practitioner do their own assessments and follow-ups, managing their own case­loads largely in parallel while coming together for team meetings to discuss issues or problems in patient care. This is less collaborative when dealing with each patient but allows for increased autonomy of the nurse practitioner.

There are several areas where collaborative care between the PNP and the psychiatrist can be compromised. The biggest pitfall might be the most obvious of any relationship: trust and communication. This is the key to any model of collaborative care. Whether working with parallel patient loads or sharing the caseload, regular meetings and open communication are necessary to allow the psychiatrist time and the PNP the opportunity to seek guidance and consultation.

The scheduling demands of psychiatry and the scarcity of time can make this difficult, but without dedicated time for collaboration of care, the natural tendency is for consultation to wait until a problem develops or a situation arises. This is contrary to the ongoing education and growth that characterize true collaborative care. When the psychiatrist is not an active participant in the care being provided by the team, patients may be at increased risk for suboptimal care.

Another barrier to effective care is not utilizing PNPs to their full potential and training, including having them administer long-acting injectable medication, perform vitals, or make an inventory of medications. This ineffective use of trained and licensed advanced practice nurse practitioners limits their ability to care for patients. In addition, it can have a negative effect on their job satisfaction and can lead to greater staff turnover and decreased productivity.

Along the same lines, assuming that PNPs can only take “straightforward” cases also limits their potential as part of the treatment team. A competent, confident, and well-supported nurse practitioner can take care of any patient who enters the clinical setting. The key to proper care and collaboration is that the nurse practitioner knows when to consult the psychiatrist for support and has access to the psychiatrist on a regular basis through collaborative team meetings and a shared electronic medical record.

 Sharing of information and freedom to consult allows the nurse practitioner to care for even the most complex patient.

The benefits of an expanding nurse practitioner workforce can be tremendous for our health system and the underserved patient populations for whom it is often a struggle to gain access to good mental health care. When properly trained, supported, and utilized, a PNP can be a cost- effective member of the treatment team who can expand access to medications needed to treat complex psychiatric disorders.

As our medical education and health care systems move forward, we must educate administrators, medical students, residents, and practicing psychiatrists on the scope and capabilities of our nurse practitioner colleagues. With increased confidence and a deeper understanding of the valuable skills they bring to the team, collaboration between the nurse practitioner and psychiatrist will be part of the solution to the workforce issue that leaves so many underserved patients without good care.

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.

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Collaboration between the psychiatric nurse practitioner and psychiatrist will be part of the solution to the workforce issue that leaves so many underserved patients without good mental health care.

Larry Malak, MD

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