Psychiatric nurses key to filling mental health gap
Nurses with special training in mental health say they have the knowledge and skills to fill the gap in care for patients who otherwise delay or wait to get help from psychiatrists, who are in short supply. They’re seeking to draw more nurses into the field as well as win the authority to write prescriptions and to work independently in Pennsylvania.
Allegheny County has 517 psychiatrists, which means one doctor for every 2,366 residents (2010 census). It’s worse in less-populated counties — for example, Armstrong, with four psychiatrists, has one doctor per 17,235 people, according to the online American Medical Association’s Health Workforce Mapper.
A national organization of psychiatric nurses launched an effort in April to call attention to their ability to step in, if they are allowed to work to the full extent and authority of their education and experience, which would mean nurse practitioners working without the oversight of a physician.
On June 12, the ranks of nurse practitioners — which include the specially trained psychiatric-mental health nurse practitioners (PMHNP) — won a victory in the Pennsylvania Senate, which voted 44-6 on a bill that would provide them with full practice authority. A similar proposal, House Bill 100, also would end the existing practice of nurse practitioners being required to secure business contracts with two physicians.
Both bills are in the House Professional Licensure Committee, awaiting the next steps before being sent to the governor for signature. The Pennsylvania Coalition of Nurse Practitioners supports these measures, saying that the contracts offer no health benefits. In 21 states and the District of Columbia they have full practice authority — they can evaluate patients; diagnose, order and
interpret diagnostic tests; and start and manage treatments, including prescribing medications and controlled substances.
The two Pennsylvania proposals would require a transition period for nurse practitioners — three years and 3,600 hours of work in a clinical setting before earning full practice authority, as regulated by the state Board of Nursing.
“There is a terrible workforce shortage in terms of the mental health profession in the state,” said Christine Michaels, CEO of NAMI Keystone Pennsylvania, a nonprofit support, education and advocacy group for people affected by mental illness. “Doctors are at the top of the list,” she said, particularly those who specialize in children.
Psychiatric nurse Wendy Zubenko, 57, of Franklin Park, said nurses like herself are ready. She’s a psychiatric-mental health clinical nurse specialist and works full time in her own practice in Pine. She maintains her CNS certification and keeps up with advances in her field, recently completing a three-day course on psychopharmacology. Because she is not permitted to prescribe in Pennsylvania, she shares some clients with her husband, a psychiatrist.
“They are kind of nurse practitioners of the mind, with the exception that our focus is a nursing focus,” she said. “It’s holistic. It’s not just look at a person with the disease and hand them the medicine. … A psych nurse knows the medicine, we also know the psychology and we know the social aspects. It’s biological, social, physical and mental.”
Currently in Pennsylvania, psych nurse credentials have been consolidated to PMH nurse practitioner (requiring an advanced degree and national certification) and psychiatric nurse generalist (requiring RN). Programs for psychiatric clinical nurse specialist have been discontinued, though existing clinical nurse specialists continue to maintain their credentials and practice.
The nurses are trained to provide effective treatment for both mental health and substance use disorders, said Gail Stern, president of the American Psychiatric Nurses Association. The group recently released a report citing a Kaiser Family Foundation study that found that only 36% of the need for mental health care has been met in Pennsylvania.
Many people have both mental illness and substance use disorder. Out of 19.6 million adults 18 and older with substance abuse disorder, 8.1 million also had mental illness, according to a 2015 national survey on both conditions. Overall in the U.S., 43.4 million had mental illness, according to the survey released in May by the Substance Abuse and Mental Health Services Administration.
Full authority sought
With full practice, Ms. Stern said, nurses could fill
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NAMI’s Ms. Michaels said, “Even with private insurance, a person needing an evaluation done may call in April and not be seen till the beginning of June. From there, they may have their evaluation and then need to see a therapist. That may take another four to five weeks to see a therapist. Then they can get a doctor’s appointment and then get medication. That’s
somebody with good insurance.” NAMI the She’s “In effort. and my board professionals researched experience strongly in the on favor community the issue, long time, mental psychiatric health, for a nurses were said. gold,” “They Ms. were Michaels helpful, they knew what they were doing, they were accessible. “I personally would have no problem having my medication filled by a nurse practitioner.” Members of the Pennsylvania Medical Society, however, oppose the legislation. “It’s not a matter of them being able to prescribe medicine,” said family physician Dr. Lawrence R. John, affiliated with UPMC St. Margaret and president-elect of the Pennsylvania Medical Society. “They want to practice independent of the health care team.”
A total health care effort involves both the nurse practitioner and the supervising physician, he said.
“We don’t feel the nurse practitioners have enough training to go out and practice,” he said. He compared the 500-720 hours of supervised training the nurse practitioner must have to the total number of supervised hours of training for a family medicine resident: 12,000-15,000 hours, which includes four yearsof medical school.
He said because nurses can get training in various programs — some in nursing school, some part time, and some online — it’s not standardized in the way of med schools and residency programs.
“That’s where the quality becomes an issue, with the minimal amount of hours, they really do need a supervising physician, particularly with more difficult or rare conditions.”
Dr. John said the medical society is promoting telemedicine services and more family physicians to better serve rural areas.
Nurses in the community
Ms.Stern said her national organization wants to garner support for all kinds of psychiatric nurses — advanced practice and RNs — and encourage more nurses to specialize in the field. The jobs are there, according to Cami Herisko, chief nursing officer and vice president of operations and patient care services at UPMC Western Psychiatric Hospital.
“There’s a big market for the advanced practice nurse, especially in our community settings,” Ms. Herisko said. “When we do hire them, we use them to the highest scope of their license.”
In ambulatory care and the MH/MR centers, she said, the nurses work with a physician, providing assessments and medication assessment. Prescribing is up to the doctor.
When asked about the shortage of physicians, Ms. Herisko said, “Recruitment of psychiatrists is an ongoing process.”
For now, she said, in community MH/MR centers, advanced practice nurses can provide psychiatric services and many different types of patient programming, including medication management.
Although there are a variety of reasons that people don’t get mental health services, she said, “More practitioners out there and available would improve access for people who do seek treatment. … The more patients we can reach and treat, the better. ... There’s no reason people should suffer with a mental health issue.”