Partnering for the Greater Good

COMMENTARY

A report published by the United States Department of Health and Human Services Health Resources and Services Administration projected that the mental health care field will be short 250,000 mental health professionals by 2025.¹ The need is most significant in rural areas, where 111 million Americans currently reside.¹ For instance in New Hampshire, where I live and practice, there are significant shortages of psychiatrists and other mental health care providers.^1,2 With the rise in the number of psychiatrists reaching retirement, psychiatric mental health nurse practitioners (PMHNPs) can play an important role in addressing these shortages.³

With this in mind, Psychiatric Times^TM invited me to be the first nurse practitioner liaison to foster the dialogue between PMHNPs and psychiatrists. Throughout my nursing and PMHNP career, I have benefited from working with exceptional clinicians—PMHNPs, psychiatrists, therapists, and other intradisciplinary team members—and I look forward to further engaging with colleagues in the mental health care field.

My clinical background has primarily been in community mental health center settings, but in the past few years I have transitioned to education as a clinical assistant professor and program director of a post-master’s PMHNP program. In this setting, I have worked with an incredible group of colleagues—psychiatrists and PMHNPs—within my department. The constant interprofessional collaboration to optimize care for a patient population with significant needs has been inspiring.

During my time at a community mental health center, that collaboration proved important. I recall one day when everything that could go wrong did go wrong. The lowest point of the day was when I learned of the death of a patient with whom I had been working for years.

After we receive terrible news like this, we so often have to set aside our grief to continue with our day—see the next patient, finish our documentation, and carry on. Trying to refocus, I marched toward a dreaded peer-to-peer phone call with an insurance reviewer, who was likely not going to approve medication. The patient in question was relatively new to me; he was a young man who, after years of struggling, had finally achieved stability. I was not inclined to change a regimen that was well tolerated and provided remission of symptoms the patient had been experiencing for the majority of his young life.

Unfortunately, just as there is stigma against mental illness and patients, there can be stigma against nurse practitioners. I sensed a problem as soon as the call began, and it was clear the reviewer held a negative view of my role. For this patient’s best interest, I realized it was neither the time nor the place to argue the bigger issue. Instead, I explained to the reviewer I was operating within the scope of practice and in congruence with nurse practitioner practice authority in my state. Astonishingly, the reviewer indicated the decision was made to deny the medication for one reason: I was a nurse practitioner. As such, the reviewer added, it was his opinion that my assessment was invalid based on my credentials and could not be used to justify the use of this medication.

I was stunned, speechless, and angry. I understand not everyone will support my professional role, but I would not allow a misunderstanding about scope of practice and this individual’s bias to interfere with appropriate patient care and the patient’s best interest. By denying the medication coverage, they were not hurting me, they were hurting the patient. That was something I could not—and would not—let go.

What was my next stop? I visited my colleague, a psychiatrist. I explained the situation, and he jumped right into action to assist me in achieving a resolution. As it turned out, the previous conversation was recorded; it was clear what had happened. The outcome was the only reasonable one: The patient’s medication was covered for the next few years.

Teams for Success

Working in mental health is not the average career in which you go home and share what happened during your workday. Thus, the connections we share with one another as colleagues in a workplace or within the same field are much more meaningful. I have found it rewarding to support not only my patients, but also my colleagues—psychiatrists, nurse practitioners, and other mental health professionals. As John J. Miller, MD, wrote in a recent editorial, we are all part of a team facing the monumental task of meeting the mental health needs of all Americans.⁴

Every PMHNP takes a unique path to the specialized education, training, and subsequent national certification to practice (On Becoming a PMHNP). Although our journeys may be different, we value hearing about our psychiatrist colleagues’ experiences. In the community mental health center setting, I enjoyed opportunities for formal and informal supervision with my psychiatrists, and we had been able to support one another throughout work and beyond. Although I no longer work in this position, I remain in contact with both psychiatrist and nurse practitioner colleagues. There is a bond that is difficult to define or put into words. Sharing a purpose and mission of facilitating optimal care for our patients as well as our goals of ongoing learning is part of this camaraderie.

As I greatly value my relationships with my psychiatrist colleagues, I also have found the world of PMHNPs to be incredibly welcoming and supportive. One thing I look forward to (among a lengthy list of other prepandemic activities) is a return to in-person educational conferences, such as that of the American Psychiatric Nurses Association.

If you have the opportunity to meet a PMHNP, whether you are interviewing them for a job or collaborating with them, take a moment to ask them why they pursued this specialty. And please tell us your story, too. Within the current health care climate (and because of the many stresses related to patient acuity, reimbursement, productivity, and prior authorizations), it is refreshing and energizing to talk with each other about why we are here and what led us to this profession. In this manner, we can better appreciate and acknowledge the similarities and differences that led us to care for patients in need of psychiatric care.

Our field promotes and appreciates collaboration and gleaning knowledge from others. I encourage PMHNP students to seek employment with an agency that provides formal supervision, regardless of state-level regulations for practice autonomy. In fact, when I was seeking my first job following PMHNP certification, I only considered positions that offered formal supervision, even though I practiced in an independent-authority state. The position I chose had the best setup for not only formal weekly supervision with a psychiatrist, but also informal open-door consultations with my colleagues at any time. One such colleague was Miller, who is Editor-in-Chief of this publication. I am incredibly lucky to have him as a resource and a mentor, along with the other wonderful clinicians and psychiatrists with whom I have had the opportunity to work.

Learning is a lifelong process, and the ability to continue to be receptive to new information and feedback is crucial for all clinicians. PMHNPs greatly value our collaboration with physicians and appreciate the many psychiatrists who have offered their expertise and time to PMHNP students and PMHNPs in clinical practice via formal or informal collaboration and supervision, mentorship, and support. I have been particularly fortunate to work with supportive psychiatrists over the years, some of whom remain close friends.

Looking Forward

I am excited to be part of the Psychiatric Times^TM team and look forward to providing an avenue for the voice of fellow nurse practitioners. Many PMHNPs and psychiatrists are already collaborating well, but I hope to facilitate even more nurse practitioner contributions and PMHNP-psychiatrist partnerships. Here’s to the start of more beautiful collaborations.

Ms Robinson is a psychiatric mental health nurse practitioner in the Seacoast, New Hampshire, area and clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

References

1. US Department of Health and Human Services; Health Resources and Services Administration, Bureau of Health Workforce; National Center for Health Workforce Analysis. National projections of supply and demand for behavioral health practitioners: 2013-2025. November 2016. Accessed March 24, 2021. https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/behavioral-health-2013-2025.pdf

2. New Hampshire Department of Health and Human Services. New Hampshire 10-year mental health plan. January 2019. Accessed March 24, 2021. https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf

3. Yang BK, Trinkoff AM, Zito JM, et al. Nurse practitioner independent practice authority and mental health service delivery in U.S. community health centers. Psychiatr Serv. 2017;68(10):1032-1038.

4. Miller JJ. Psychiatry 2021: team psychiatry. Psychiatric Times. 2021;38(3):10-11. ❒