A Community Psychiatry Nurse Practitioner Fellowship: Preparing Nurse Practitioners for Mental Health Workforce Expansion

The increasing demand for psychiatric services is projected to overtake the supply of psychiatrists by 12%–25% in 2025 (1). The American Psychiatric Nurses Association (2) released a report indicating a projected shortage of 250,000 mental health professionals by 2025. This decline is attributable to aging of the current workforce, high expected retirement rate (3), and a national shortage of psychiatry residency slots (4) in addition to the increased demand for services. The shortage of mental health services is especially concerning in medically underserved areas, such as rural populations, urban neighborhoods, and community health care centers, and is expected to have a disproportionate impact on racial-ethnic minority groups with higher levels of unmet mental health needs (2).

Psychiatric and mental health nurse practitioners (PMHNPs) are beginning to address the nation’s shortage of mental health providers. According to a 2017 report by the National Council for Behavioral Health, 13,815 PMHNPs were practicing in the United States, and this number is projected to grow to 17,900 by the year 2025 (1). Although this workforce expansion will not be sufficient to meet the needs of the nation’s communities, several states have demonstrated that PMHNPs are effectively stepping forward to fill gaps in care (2). However, working in federally qualified health centers (FQHCs) and community health centers is often associated with challenges related to high staff turnover while serving patients with complex medical, behavioral, and psychosocial needs (5). These challenges can be especially difficult for the new clinician. The adjustment into practice from academia can influence the development of the practitioner’s role, the practitioner’s confidence, and whether the practitioner chooses to remain in the position—and even in the profession—within the first year of practice (6). Community health organizations can address these challenges by implementing formal mentorship to new nurse practitioners (NPs) entering the workforce. Mentorship during the first year of practice can provide additional guidance and support to facilitate the transition from novice NP to experienced clinician (7).

FQHCs are nonprofit, community health centers that deliver comprehensive health care and social services in underserved areas to patients regardless of insurance or ability to pay. Approximately 91% of patients who receive care at FQHCs are at or below the 200% of the federal poverty level, about two-thirds of patients belong to racial-ethnic minority groups, and nearly one-fourth are best served in a language other than English (8). At a minimum, all health centers that receive grant funding from the Health Resources and Services Administration under Section 330 of the Public Health Service Act are required to provide referrals to substance abuse and mental health providers. Nearly three-quarters of health centers had onsite mental health or substance abuse treatment staff in 2010, and they provided more than 5.2 million encounters (8). Additionally, in 2010, patient encounters for depression were the third most frequent encounters, following hypertension and diabetes (8).

The community mental health setting highlights the advantages of utilizing interdisciplinary teams in delivery of care (9). PMHNPS are an invaluable source for designing and providing mental health care and leading and working within interprofessional teams within the rapidly changing field (10). PMHNPs hold master’s or doctoral degrees and provide a full range of mental health and psychiatric services. They assess and diagnose, prescribe medications, provide psychotherapy, provide consultation and liaison services, and participate in policy and research development (2). All 50 states grant PMHNPs prescriptive authority to some level. In New York State, NPs may prescribe independently after completing 3,600 hours of practice with a collaborating physician and written protocols.

The PMHNP certification granted by the American Nurses Credentialing Center requires 2,000 hours of clinical practice during academic training. However, the placements and experiences of clinical practicums can vary widely by setting, experience of preceptor, and population of patients in regard to demographic characteristics, diagnoses, and symptomatology. The Institute of Medicine’s Future of Nursing report (11) makes the recommendation to implement residency programs for both undergraduate and advanced practice nurses to support the transition into practice. Delaney and Vanderhoef (10) also recognized the value in postgraduate training programs and suggested that these programs will support and expand the PMHNP workforce with a specialty focus given the complexity of the population and their mental health needs.