Psychiatric Nurse Practitioners: Supporting “Top of License” Function to Enhance Care Access
- Posted by Ana Hategan
- Posted in Brief Review, Editorials & Commentary
JPR Vol 11 #4 February 14, 2022
Rini Dass, B.ScN., M.ScN., Adult-N.P.1,✉, Ana Hategan, M.D.2,iD, James A. Bourgeois, O.D., M.D.3
1 Assistant Clinical Professor, Adult-Nurse Practitioner, McMaster School of Nursing, McMaster University, St. Peter’s Hospital, Hamilton, ON, Canada. ✉ [email protected].
2 Clinical Professor, Geriatric Psychiatrist, Division of Geriatric Psychiatry, Department of Psychiatry and Behavioural Neurosciences, Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada. [email protected]. ORCID iD: https://orcid.org/0000-0003-0221-1154.
3 Clinical Professor, Consultation-Liaison Psychiatrist, Chair, Department of Psychiatry, Baylor Scott & White Health, Central Texas Division; College of Medicine, Texas A&M University Health Science Center, Temple, TX, USA. [email protected].
This article aims to increase awareness regarding how nurse practitioners potentially can mitigate the gap in clinical care in the midst of psychiatric clinician shortage. In this view, it provides an outline on how the health care system can utilize nurse practitioners’ full scope of practice to work at the top of their license. This could allow tapping into this workforce to undertake the role of the most responsible provider to enhance care access.
What the problem is
There has been heightened awareness recently of the importance of making global psychiatric care an integral part of sustainable development, and this is demonstrated by the inclusion of mental health care in the Sustainable Development Goals . The Sustainable Development Goals are the United Nations’ proposed actions to achieve a better and more sustainable future for all . In this view, the World Health Organization set out the 2013-2030 Comprehensive Mental Health Action Plan outlining four main objectives including: 1) the implementation of strategies for promotion of mental health and prevention of illness; 2) the provision of comprehensive, integrated mental health and social care services in community-based settings; 3) more effective leadership and governance for mental health; and 4) enhanced population-based information systems, evidence and research . To meet these needs, current health care systems should contemplate how to allocate future resources, as well as reallocate existing resources, more creatively.
The need for mental health care in Canada is greater than ever. There is a gap in care currently which is estimated to grow even larger with time . By 2030, the number of psychiatrists per population has been estimated to decrease by 15% . The frequently quoted ratio of psychiatrists to population in Canada has been between 1:6,500 and 1:10,000, where an upper limit to this ratio is desirable . This is similar to the Royal Australian and New Zealand College of Psychiatrists’ recommended range of 1:7,500 to 1:10,000 . In the USA, the psychiatrist workforce has also been estimated to contract if no interventions are implemented, leading to a significant shortage of psychiatrists by 2024 .
Many patients with psychiatric disorders need specialized care. Patients in Canada, particularly those residing in rural, remote and underserviced communities, will face further challenges in receiving specialized care for the sickest populations due to this shortage of psychiatrists. The importance of having psychiatric clinicians available to provide expert assessments including timely psychiatric evaluations, psychiatric care, and follow-up, as well as the ability to work collaboratively in a shared model with primary care physicians (PCPs), cannot be underestimated.
As it is normative for psychiatric illness treatment in primary care to include psychotropic medications, there is a need for specialty consultative care by practitioners trained and skilled in psychopharmacology. As non-medical psychotherapists of various mental health disciplines are not trained in medical management of psychiatric illness, there is a need for additional practitioners with this skill set. In most health care systems, where psychiatrists are concentrated in urban areas and/or at university hospital settings, there is inadequate access to psychiatrists, particularly in rural and frontier areas. Telemedicine services by psychiatrists can help to decrease the geographical distance problem, but it is unlikely that there will ever be enough psychiatrists to fully support the primary care system. The nurse practitioner (NP) workforce can be a productive resource to fill in the gap and address, at least in part, this shortage of psychiatrists.
What was tried
Enabling NPs a maximum scope of practice through contributions as the most responsible providers (MRPs) can be valuable across a continuum of health care settings. Physicians cannot fill every need. To fill this care need gap, nursing regulatory oversight bodies (in theory) already allow NPs to work at the full scope of their education and training, and thus (in clinical realm) NPs should be given all opportunities to do so. Operating at “the top of license” means the clinician practices to the full extent of their training, while limiting time performing tasks that could be accomplished by someone else with less education, skill, and experience [7, 8]. NPs work both autonomously and collaboratively with other health care professionals in a wide range of settings including acute and chronic care hospitals, outpatient and outreach clinics. NPs are authorized to diagnose illnesses, order and interpret diagnostic tests and prescribe medications and other treatments for patients [7, 8]. NPs can consult any specialty. According to the College of Nurses of Ontario, NPs are authorized to admit and discharge hospital patients; however, the process for an NP to admit and discharge patients is up to the discretion of the hospital and its respective policies .
NPs are advanced practice nurses with graduate level of preparation. There are two ways to complete an NP degree in Canada: a) most NP programs include a master of nursing-nurse practitioner field of study program, and b) some universities also offer a post master NP program (e.g., University of Toronto). Although NPs are designated by training as pediatric, adult, and primary care NPs, any NP can also work in the mental health system. However, thus far in Canada, only the province of Quebec offers specific training for NPs in mental health . It is the hope that other provinces will offer more intensive psychiatric training levels. It is especially desirable to provide graduate-level psychiatry and psychopharmacology training for NPs, as well as to network them with consulting psychiatrists, to partially address this shortfall. Indeed, an important additional pedagogic role for academic psychiatrists, in addition to their education of physicians, is didactic and clinical instruction in training programs for NPs.
NPs are licensed by the respective provincial College of Nurses . The NP role was first implemented in Canada in the 1960s. In 1997, it became a regulated profession in order to meet the primary care needs at the time. The NP scope of practice has broadened over time . In 2012, the Canadian government passed legislation to grant NPs an additional prescribing authority for controlled medications . Undoubtedly, the NP role has expanded since the 1960s; however, there is still a need for leaders to further advocate for the NP role, address barriers to full scope of practice, and successfully implement and sustain the role.
In this vein, there is emerging evidence regarding how NPs in various specialties can practice at the top of their license to improve access to care, enhance patient satisfaction, and decrease acute care hospitalizations [11, 12]. A study by David et al.  showed that NPs working in cardiac acute care settings had a significant impact on lowering the rate of hospital readmissions and return to emergency department within 30 days. A review by Woo et al.  suggested that the NP role in critical care and emergency department also had a positive impact on patient outcomes. By inference, psychiatry is another area where the NP role could be integrated to improve access to psychiatric care. Especially in northern, rural Canada and other austere, resource-limited settings, the NP role could help with meeting the care needs of underserviced and under-represented populations. To address the issues of health equity in psychiatry, it is plausible that NP-led programs could play a role in increasing access to psychiatric care, improving outcomes in patients, and reducing hospitalizations.
Lessons learned about NPs as MRPs: Discussion and implications
NPs have a wide scope of practice that is valuable to population health. Innovative models of care that include the NP role in long-term care settings have already been demonstrated [11, 12, 15]. Moreover, since the onset of the COVID-19 pandemic, there have been long-term care settings where NPs have increased their role as MRPs to provide care and expertise [11, 12]. An emergency management act issued in March 2020 in Ontario enabled NPs to act as the MRP and work as medical directors in long-term homes in need . Therefore, the COVID-19 pandemic has highlighted that NPs can have a specific scope of practice, which positions them well to act as leaders in building capacity in communities, as well as in establishing links between fragmented systems of care .
There has been a paucity of studies to demonstrate the potential for NPs in the Canadian mental health care system to add value to psychiatric programs, but future research can have significant implications for improvements . Kant et al.  already argued about the effectiveness of NPs as the MRP in three separate outpatient psychiatric programs in the province of Ontario, including the successful implementation of the NP role as MRP in an assertive community treatment team (ACTT) setting in 2016, a transitional aged youth outpatient program in 2015, and an adolescent outpatient program in 2013.
Although there is evidence about the effectiveness of the NP roles, including as the MRP, there are institutional and system barriers to the introduction, implementation and sustaining NP roles. Some examples of the cited barriers are lack of understanding of NP roles and lack of leadership, support and funding . Some degree of physician opposition to NPs practicing without physician supervision in general is not new and adds to the list of barriers . These barriers exist in practice, at systems and organizational levels, which requires consideration .
While psychiatric NPs cannot be seen as “interchangeable” with psychiatrists, they are grounded in nursing and medical management, making them of great utility as specialty consultants to frontline PCPs. A model wherein psychiatric NPs can collaborate with psychiatrists in a shared care model and also have the capacity to refer to psychiatry for more complex patients seems like an attainable goal. In rural, remote places, the psychiatric NP could receive referrals from PCPs and co-manage with them patients that were overly complicated for primary care alone but not yet needing psychiatry consultation or referral. We propose an algorithm to help devise an ideal role for psychiatric nurse practitioners (NPs). In this model, routine psychiatric care could be performed by PCPs and/or psychiatric NPs, while the more complex cases may require the care of a psychiatrist. Psychiatrists must see hospital-based consultation-liaison (ED/ICU/wards) psychiatric cases, attend to toxicology management, apply rTMS, ECT, and esketamine treatment, manage complex medication algorithms (e.g., lithium, anticonvulsants, antipsychotics, antidepressant combinations), manage disorders such as schizophrenia, OCD, delirium, dementia, complex drug abuse, and patients with complex medical co-morbidity. Psychiatric NPs could see (with psychiatric consultation as necessary) 2nd/3rd line depression treatment, anxiety disorders, straightforward substance misuse, and most personality disorders. PCPs can see frontline/initial presentations. Therefore, PCPs would need NPs for a first-level psychiatric consultation to help them particularly when psychiatric consultants are not readily available.
Therefore, developing specific models whereby a consulting psychiatrist could (via telemedicine, for instance) collaborate in a shared care model with several NPs in remote locales via regular consultation, including supervision on more complex patients, can certainly be implemented. Other models could include a NP working at remote inpatient psychiatric unit with access to psychiatrist by videoconference for consultation or shared care collaborative model; a hub-and-spoke network for remote mental health clinics, each run by a NP with collaborative capacity with a psychiatrist; and so on.
We propose that psychiatric NP could even collaborate with psychologists/social workers and other non-medical mental health professionals on the medical aspects of psychiatry. In a multidisciplinary team, it is essential to keep in mind the NP’s scope of practice that allows them to prescribe medications while non-medically trained mental health professionals cannot; medical management is clearly delegated to psychiatrists and NPs whereas the mental health non-medical management can be rendered by psychologists, social workers, and others.
In summary, research has already shown that employing NPs at long-term care homes can lead to an increased access to care while providing safe and cost-effective care, improved health outcomes and patient/family satisfaction, and decreased hospitalization rates [11-14]. Future evidence-based intervention strategies managed by NPs as the MRP in other care settings are needed. NP-led psychiatric services to meet complex care needs, particularly in underserviced locations, would be a timely, safe, and an innovative quality caring solution to human resource challenges. Therefore, the NP role can have the potential to mitigate the gap in care in the midst of psychiatric clinician shortage. These interventions will be difficult to sustain without dedicated resources. Full implementation and sustainability for this model of care needs further research and exploration.
Future practice points
- NPs can be a viable solution to partially address the shortage of psychiatrists especially in remote and underserviced areas, during and beyond the current pandemic era.
- Ensuring models such as attending psychiatric NPs versus NP-led psychiatric clinics must align with the needs of the local region.
- Such models of care may help increase access to psychiatric care but also reduce the need for specialist care for the sickest populations.
- An integrated team concept, with disciplines that focus on overarching goals such as developing patient-centered team care, reducing quality care gaps, and educating an interprofessional workforce, is desirable. Further research is essential in these areas to shed light.
- Table 1 summaries some of the main NP roles as MRPs and responsibilities necessary for the delivery of high-quality psychiatric care.
Table 1. Nurse practitioners as most responsible providers (MRPs): responsibilities for the management and coordination of psychiatric care.
|Help increase access to, and quality of, psychiatric care in primary health care and/or institutional settings||Responsible for psychiatric screening and assessment, timely specialist referrals to other specialties, follow-up psychiatric care, ongoing chronic psychiatric disorder management across the life span, and address end of life care|
|Provide direct and indirect care
|Responsible for continuity of care, in-person and/or virtual
Improved care coordination and collaboration across the care continuum among health care providers in the region
Provide psychopharmacological treatment (including medication combinations) in accordance with standardized treatment algorithms
Utilize therapeutic drug monitoring according to standard protocols
Interface with non-medically trained psychotherapists who are also involved in patient management
|Provide education||Focused on effective patient education
Provide formal rounds and presentations, clinical instruction in specific areas of expertise, and supervision of day-to-day care provided by other clinicians or trainees to patients in the office or home visits
|Implement evidence-based practices||Accountable for creation and implementation of evidence-based practices, and increased knowledge capacity building|
|Conduct quality improvement plans and research activities||Accountable for quality improvement projects and research|
|Undertake leadership activities||Participate in internal and external committees|
Conflict of Interest
The authors report no conflicts of interest concerning the subject matter of this article.
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