Psychiatric mental health nurse practitioners (PMHNPs) provide mental health services and medication management to patients in both inpatient and outpatient health care settings. PMHNPs’ responsibilities are very similar to those of a psychiatrist in that they typically prescribe medications, monitor patient progress on these medications, and incorporate psychotherapeutic modalities into their sessions with patients. Inpatient psychiatric settings include emergency departments and acute inpatient psychiatric units. PMHNPs in intensive inpatient settings tend to focus on patient safety, short-term stabilization, and creating a psychiatric treatment program that enables patients to continue addressing their mental, physical, and behavioral health challenges after discharge from inpatient care. Outpatient psychiatric settings include outpatient behavioral health centers, community health clinics, and private practices. PMHNPs who work in outpatient care typically provide medication prescriptions, consultations, and ongoing management, as well as psychotherapy to patients both individually and in groups.
Mental health is both a crucial and an underappreciated aspect of people’s overall well-being; individuals who struggle with psychological, emotional, and behavioral issues may find that their mental health dramatically impacts their ability to function optimally in social, professional, and familial settings. The stigma around mental illness and the fact that many health insurance companies do not prioritize behavioral health can also prevent many people from seeking the help that they need. Due to these and other factors, advanced psychiatric mental health nursing can be a very impactful field, as PMHNPs support individuals in very great need, with the goal of empowering them to address their mental health challenges and build healthy habits so that they can function well in society.
To become psychiatric mental health nurse practitioners, registered nurses must complete a graduate nursing program with a concentration in psychiatric mental health nursing at an institution that has been accredited by either the Commission on Collegiate Nursing Education (CCNE) or the Accreditation Commission for Education in Nursing (ACEN). During their program, students must also complete a minimum of 500 hours of clinical practicum in settings relevant to inpatient and/or outpatient psychiatric care. After graduating, prospective PMHNPs must pass a national certification exam administered by the American Nurses Credentialing Center (ANCC), and also consult their state board of nursing in order to determine and obtain any requisite state-based licensing prior to practicing.
Where Psychiatric Mental Health Nurse Practitioners Work
Psychiatric mental health nurse practitioners can work in a wide variety of settings, from outpatient mental health clinics to emergency departments to psychiatric wards within hospitals and community health settings. Below is a more detailed description of some of the common settings in which PMHNPs work.
Psychiatric mental health nurse practitioners can work in emergency departments and other acute care settings, where they assist with the patient intake and triage process by conducting mental health evaluations and providing psychiatric stabilization and support to patients who need it. Some emergency departments have a designated section with a separate staff of mental health professionals to evaluate, diagnose, and stabilize patients.
The care that PMHNPs provide in emergency settings is typically short term, with the aim of stabilizing the patient before his or her transfer to inpatient clinics, an outpatient clinic, or home. PMHNPs also assist with the discharge and/or transfer of patients to acute inpatient or intensive outpatient psychiatric settings if needed. They work in collaboration with physicians, other nurse practitioners, critical care nurses, social workers, medical assistants, and other intensive care staff.
Charlie Myers, MSN, PMHNP-BC is a Psychiatric Mental Health Nurse Practitioner at John Muir Behavioral Health Center (JMBHC), where she cares for patients with chemical dependencies. Prior to this role, she worked in the Emergency Department and the Acute Inpatient Psychiatric Unit at Johns Hopkins School of Medicine. In an interview with OnlineFNPPrograms.com, she described how the nature of her work and the patient population she served in the Emergency Department and the Acute Inpatient Psychiatric Unit differed from those of her current position at JMBHC. “At Johns Hopkins Medicine, I worked performing psychiatric evaluations in the emergency room as well as admitting patients to the acute psychiatric unit and performing psychiatric consults on the medical floors. The types of patients I saw were more varied in their diagnoses and often much more psychiatrically unstable than the patients I see at John Muir Behavioral Health,” she said.
Ms. Myers also noted that, unlike the patients she treats at JMBHC, the patients who were admitted into the Emergency Department and the Adult Inpatient Psychiatric Unit at Johns Hopkins often posed a danger to themselves and/or others due to the severity of their psychiatric condition. “At JMBHC, I work mainly with patients who are suffering from chemical dependency and are undergoing treatment for detox. While they may have comorbid psychiatric conditions, they are not a danger to themselves or others such as the patients I was caring for at Johns Hopkins,” she said, “The patients I am caring for at JMHBC are all in the program on a voluntary basis, while many of the patients I was caring for at Johns Hopkins were in treatment and under involuntary psychiatric holds due to being a danger to self or others or gravely disabled due to psychiatric illness.”
Inpatient Psychiatric Care Settings
PMHNPs can also work in specialized inpatient settings. Inpatient psychiatric treatment programs and facilities typically require patients to attend behavioral therapy sessions during the day, and also consult with psychiatric professionals such as psychiatrists and PMHNPs to discuss, develop, and implement an effective medical treatment plan. Different tiers of inpatient psychiatric care serve patients with varying severities of mental illness. Examples of inpatient psychiatric care settings include but are not limited to:
- Psychiatric Hospitals, also known as psychiatric wards, are subunits of larger hospitals and medical centers that serve patients specifically suffering from serious psychiatric illnesses such as schizophrenia, bipolar disorder, clinical depression, and/or chemical dependency. Patients may be admitted on a voluntary or involuntary basis to psychiatric wards, and once admitted, they typically receive intensive and multidisciplinary psychiatric and medical care, including medication management, 24/7 monitoring, and mental health counseling and support.
- Residential Treatment Programs include substance abuse treatment programs, eating disorder treatment programs, and programs supporting patients with severe anxiety and/or depression. Residential treatment programs are one step down from psychiatric wards in that they serve patients who are not an immediate danger to themselves or others, but who nevertheless need considerable psychiatric support and structured care.
Relative to emergency departments, inpatient psychiatric settings provide longer-term care to patients who are struggling with complex psychiatric/mental health and behavioral problems. In addition to providing psychological counseling and medication management, PMHNPs may also assist in their patients’ transition from inpatient settings to outpatient care or home.
When elaborating further on her role at John Muir Behavioral Health Center, Ms. Myers explained how her work with patients suffering from chemical dependency involves progressive work, typically over the course of several weeks, to help patients detoxify from their substance abuse, build better self-care habits, and work to address their addiction. “I perform psychiatric evaluations on chemical dependency patients who are hospitalized on the inpatient detox unit. I assess them for the presence of mood disorders and other psychiatric complications and determine whether or not psychiatric medications are indicated and prescribe them as needed. I monitor the patients daily as detox progresses and titrate medications as indicated,” she said, “I also manage patients and their medications once they are discharged to the outpatient and residential chemical dependency treatment programs […and] facilitate educational groups for patients on the unit on topics such as anxiety management, sleep hygiene, medications commonly used in detox, etc.”
Outpatient Behavioral Health Clinics and Centers
Outpatient behavioral health settings treat patients experiencing psychological, emotional, and behavioral health problems that are not so severe that they require inpatient treatment, but which negatively impact their daily life. These clinics can also receive patients who have completed treatment at an inpatient treatment facility and are ready for a lower level of care, but who still need structured support.
Outpatient behavioral health settings include clinics that are affiliated with a larger medical center, or behavioral health centers that stand alone and provide counseling and psychiatric services. Psychiatric mental health nurse practitioners who work in these settings seen patients for sessions during which they may provide psychological counseling and medication management services. Levels of outpatient care can range from intensive outpatient to routine outpatient care:
- Intensive Outpatient Programs (IOP) and Partial Hospitalization Programs (PHP), also known as Day Treatment Programs, are a step down from residential treatment programs in that patients are not housed at a facility, but instead travel to a hospital or other treatment setting to attend structured psychiatric counseling and receive medication management services. PHPs and IOPs are largely equivalent in terms of the treatment services provided, with the main difference being the number of hours required for patient attendance (PHP is generally more than IOP).
- Routine Outpatient Care (ROC) is the least intensive level of psychiatric care, and consists of individual and group therapy sessions that patients attend on an as-needed basis, according to their own schedule. Depending on the patient’s needs, ROC may also include medication counseling and management.
Outpatient psychiatric care often involves a longer-term patient-provider relationship, relative to inpatient settings where the primary goal is stabilization and de-escalation of very severe conditions. Andrew Penn, RN, NP, CNS, PMHNP-BC is a Psychiatric Nurse Practitioner III at The Permanente Group in California, where he has worked in outpatient psychiatry for over a decade. “In my clinic at Kaiser Permanente, I am part of a team that is comprised of psychotherapists (Licensed Clinical Social Workers, Marriage and Family Therapists, and Psychologists), another Psychiatric Nurse Practitioner, Registered Nurses, and Psychiatrists,” he explained in an interview with OnlineFNPPrograms.com, “In my particular clinic, my responsibilities are very similar to those of my psychiatrist colleagues–we all see patients for initial intake assessments, start and monitor medications, and follow these patients over time.”
Another outpatient setting that employs PMHNPs is psychiatric private practices. Depending on their state of residence and their individual certifications and qualifications, PMHNPs may also be able to establish their own private practices. Registered nurses who are interested in becoming PMHNPs and creating their own private practices should check with their state’s regulations around independent practice for nurse practitioners.
Psychiatric private practices typically provide psychological counseling by appointment and medication management services to clients struggling with mental, emotional, and behavioral health issues. PMHNPs in private practice settings typically collaborate with a team comprised of one or more psychiatrists, psychiatric nurses, licensed clinical social workers, and other PMHNPs. In private practice settings, PMHNPs prescribe medications, provide individualized counseling on ways that patients can manage their mental and emotional conditions in conjunction with medical treatment, and make adjustments to patients’ medications as needed.
Community Health Centers
Community clinics and health centers provide free or low-cost/sliding scale psychological and behavioral health counseling and support to members of the community. These outpatient care settings may offer individual and group counseling sessions on a by-appointment and/or walk-in basis. As the mission of community health clinics is to provide affordable care to the community at large, PMHNPs who work in these settings will often encounter different patient populations than if they were to work in private practices or specialized clinics in hospitals.
Laura Hickman, MSN, FPMHNP-BC is a Family Psychiatric Mental Health Nurse Practitioner who works at Southwest Behavioral & Health Services (SBH), a network of community-based mental health centers. Ms. Hickman also worked at a variety of private practices during her MSN program, and in an interview with OnlineFNPPrograms.com, she explained the distinction between private practice settings and community health clinics. “Most clients in the private practice world are two-income households and are raising children that may be struggling with ADHD or Autism, or mom or dad may be struggling with anxiety or depression. The needs of these clients are much different than the patients in community mental health, who struggle with finances, chronic health conditions, low education levels, domestic violence, lack of health care knowledge or treatments, chronic pain, and substance abuse, alongside with a mental health diagnosis,” she said, “This is not to say that there are not these struggles in private practice, but the day-to-day challenges are more prevalent for those served in community mental health.”
Telemedicine is a growing field, with nurse practitioners and other providers across various specialties engaging in remote patient appointments and consultations more frequently in order to meet the growing need for timely medical advice, prescriptions, and services. Outpatient psychiatric mental health is a field that may lend itself well to telemedicine services, as psychological evaluations and counseling are typically completed through patient discussions and interviews rather than physical examinations.
In addition to her in-person work with patients at an outpatient clinic, Ms. Hickman works at SBH’s Tele Medicine Payson Clinic, where she conducts psychiatric evaluations and medication consultations and management, serving patients in rural areas and those who are unable to commute to a medical center. “Tele-medicine utilizes video and audio to communicate with clients that may not have services available to them in their area,” she explained in her interview with OnlineFNPPrograms.com, “The provider speaks with the client via video connection, much like Skype or Face Time, and is live and interactive. Interview techniques and establishing a relationship with the client are tailored via tele-medicine, and is fully capable of meeting the treatment needs of the client.”
What Psychiatric Mental Health Nurse Practitioners Do
Psychiatric nurse practitioners function very similarly to psychiatrists in medical and mental health care settings, in that they conduct initial and ongoing psychiatric evaluations of patients, develop mental health care plans, and coordinate the care of their patients (ex. facilitating both the intake and discharge/transfer processes for patients). PMHNPs also educate patients in the proper management of their mental health challenges, participate in research and/or the development of mental health programs that serve the larger community, train staff and medical residents, and precept students. Below is a more detailed description of some of the core responsibilities that psychiatric mental health nurse practitioners complete in their work.
Just as physical health assessments are one of the primary responsibilities of nurse practitioners who treat physical ailments, so psychiatric evaluations are central to the work that PMHNPs do. Psychiatric mental health nurse practitioners complete psychiatric assessments during a patient’s admission into a given health facility, whether that be an intensive inpatient care setting or an outpatient behavioral health clinic.
According to the American Psychological Association, psychiatric evaluations involve interviewing a patient about their mental health and medical history (known as a clinical interview), reviewing any previous records of mental health diagnoses and treatments, and conducting specific psychological tests to determine the type and severity of mental health issues that a patient is currently struggling with, such as obsessive compulsive disorder, generalized anxiety disorder, Alzheimer’s, attention deficit and hyperactivity disorder, etc. During their completion of a psychiatric evaluation, PMHNPs also make note of physical, social, and behavioral issues that may connect to their patients’ psychological health challenges, and vice versa.
Psychiatric evaluations are key to ensuring that patients receive targeted treatments and psychological support that truly address their individual challenges. Depending on whether their relationship with the patient is short-term or long-term in nature, PMHNPs may conduct several psychiatric evaluations to gauge a patient’s progress on a given treatment plan. PMHNPs will often discuss the findings of their evaluations with the other members of the treatment team in their work setting.
Development and Tailoring of Psychiatric Treatment Plan
After completing psychiatric evaluations, PMHNPs will typically collaborate with other members of their care team to develop a psychiatric treatment plan for their patients. Psychiatric treatment plans vary depending on the care setting (inpatient versus outpatient), as well as the individual needs, goals, and preferences of the patient.
In an inpatient care setting, a psychiatric care plan will often involve plans for patient stabilization (including providing medical services to patients with concurrent medical issues, monitoring patients who are in danger of self harm, and administering medications as necessary), a progressive plan for psychiatric medical treatment, and highly structured and intensive mental health counseling. PMHNPs will monitor their patients’ responses to different medications and adjust accordingly over time.
In outpatient mental and behavioral health settings, treatment plans are generally less structured, with the exception of intensive outpatient programs which often involve group and individual counseling that patients typically must attend for several hours, several times a week. PMHNPs working with patients in outpatient settings will often develop psychological care plans that may include individual counseling as well as group counseling sessions on a weekly basis, as well as prescriptions for medication and ongoing monitoring of patients’ responses to their psychiatric treatment.
Medication Management and Psychological Therapy
After developing a plan of care for their patients, psychiatric mental health nurse practitioners typically see patients on an individual basis to review their medications and to provide mental, emotional, and behavioral health counseling as needed. The amount of psychological counseling that PMHNPs complete relative to their medication management responsibilities can vary depending on the setting in which PMHNPs work.
Emily Weston, MSN, PMHNP-BC, is a Psychiatric Mental Health Nurse Practitioner at Wentworth Health Partners, where she conducts psychological evaluations, prescribes and manages medications, and coordinates the care of patients. In an interview with OnlineFNPPrograms.com, she explained how her current role involves more prescribing and medication adjustment and guidance, rather than clinical psychotherapy, though she is trained in both disciplines. “PMHNPs, like psychiatrists, can prescribe medications, which is one of the main differences between PMHNPs and other mental health providers such as psychotherapists and clinical social workers,” she said, “In fact, for most of my career that is what I have focused on, psychopharmacological management of mental health diagnoses. We are trained to administer psychotherapy as well, but because the need for providers who can provide psychiatric medication management is so great, PMHNPs have functioned as the prescribers for the most part. I did see patients for psychotherapy when I was first practicing, but due to the needs of the practice, I started strictly seeing patients for medication management about two years into my career.”
Despite the emphasis of medication management in her current role, Ms. Weston also noted that, as psychiatric medications must be taken in conjunction with patients’ conscious efforts to make positive cognitive and behavioral changes, she incorporates mental health counseling and employs psychotherapeutic techniques into her medication consultations. “There are elements of counseling in every visit even though the primary purpose is to discuss medications,” she noted,
[H]owever, most patients are also seeing another provider for psychotherapy. I try to keep in touch with whomever they are seeing to ensure continuity of care.”
In other mental health care settings, PMHNPs might focus more on clinical psychotherapy as opposed to primarily medication management. In her interview with OnlineFNPPrograms.com, Ms. Myers noted, “In general in the places where I have worked, the social workers and psychotherapists tend to focus on performing psychotherapy and groups with the patients and the PMHNPs and psychiatrists tend to focus on the psychiatric evaluations, diagnoses, and medication management side of things. I have only worked in a hospital setting, but do have some NP friends who work in private practice and do perform psychotherapy with their patients.” PMHNPs receive training in psychotherapeutic modalities to support a wide variety of mental, emotional, and behavioral health conditions. These modalities include but are not limited to:
- Cognitive Behavioral Therapy (CBT): CBT is a type of psychotherapy that involves guiding patients through exercises that help them examine and better understand the relationship between the core values and beliefs that they hold, and the daily thoughts and consequent feelings that lead to problematic and/or self-destructive behaviors. Patients using CBT will often record their thoughts and feelings, connect their thoughts and feelings to the behaviors they would like to change, and also work with mental health practitioners to identify the underlying beliefs contributing to self-destructive thought patterns and behaviors.
- Dialectical Behavioral Therapy (DBT): Is a modality that incorporates elements of CBT and combines it with mindfulness practices and principles. Initially developed to support patients struggling with Borderline Personality Disorder, DBT is now used more widely among patients who want to build emotional regulation skills and also address self-destructive and problematic behaviors.
- Motivational Interviewing (MI): MI is a form of psychotherapy that guides patients through the process of identifying their own challenges and their own solutions to their problems through targeted questions that aim to empower rather than instruct the patient. MI focuses on gauging a patient’s readiness to make positive life changes, any ambivalence he or she may have for making changes and the reasons behind this ambivalence, and the types and degree of effort that will be required for a patient to meet his or her goals.
- Harm Reduction Techniques: Harm reduction techniques focus on realistically preventing and/or reducing the negative consequences of problematic behaviors, as opposed to eradicating these behaviors entirely. It is often used in combination with other therapeutic methods so that patients can maintain their well-being while working slowly on gradual mental, emotional, and behavioral changes.
- Supportive Psychotherapy: Therapists and mental health practitioners use supportive psychotherapy when their patients need emotional support and positive reinforcement. In contrast to CBT, DBT, and more analytical forms of psychotherapy, supportive psychotherapy focuses on encouraging patients, giving them a safe space to express their concerns and other negative emotions, and celebrating patients’ successes as a way to build their confidence in realizing further change moving forward.
In addition to medication management and targeted psychotherapeutic techniques, PMHNPs take into consideration their patients’ overall health. In her interview with OnlineFNPPrograms.com, Ms. Hickman explained the importance of holistic care in the work she does with patients. “Patient education and coordination of care are key components for quality-based care in this setting. Treatment plans are individually tailored to best meet their challenges. Chronic pain, poor nutrition, chronic and severe health conditions, socio-economic issues, lack of education, and transportation issues are just a part of their needs,” she said, “It is a necessity to balance their physical and their mental health and for them to have an understanding of the importance of the relationship between the two. […] Chronic conditions, such as a thyroid disorder, or diabetes can greatly affect their mood symptoms and so tailored treatment goals must be addressed in order to stabilize their mood.”
Care Coordination Services
PMHNPs often work as part of a larger group of medical, mental health, and social services professionals to provide optimal care to their patients. Psychiatric mental health nurse practitioners coordinate the care of their patients by communicating with the different parties involved in the medical, psychological, and social care of a particular patient, and by assisting with patient intakes and transfers to other care settings or home.
In her interview with OnlineFNPPrograms.com, Ms. Hickman explained, “[PMHNPs] work with teams of therapists, medical assistants, nurses (both LPN and RN), case managers, substance abuse counselors, high needs treatment teams, crisis response teams, and also with those health care professionals outside of SBH. A collaboration of care between primary care and psychiatry has been recognized by SBH and they have made this transition into collaborating care.”
Care coordination involves a combination of many different tasks and organizational responsibilities, as well as consistent medical record-keeping and communication among various care providers. “Examples [of care coordination responsibilities] are Peer-to Peer telephonic conversations with the client’s inpatient provider prior to discharge, coordination of discharge by the Transition Specialist, a specific team member that coordinates the transition back to outpatient care, and the capability to directly communicate with the Primary Care Provider (PCP). This helps reduce costs and improve treatment outcomes,” Ms. Hickman noted.
Research, Program Development and Education
In addition to their individual work with clients, PMHNPs can participate in clinical mental health research and engage in the development of programs that serve particularly vulnerable or underserved populations. Hospitals and community health centers can have outreach and educational programs for members of the community on substance abuse, anxiety disorders, depression, eating disorders, and other mental and behavioral health issues and their prevention and treatment. PMHNPs may also find opportunities to conduct research on clinical mental health issues and treatment methods, in collaboration with other practitioners and researchers in a university or hospital setting.
As coordinators of care and leaders in mental health settings, PMHNPs can also train and guide staff, precept nursing students, and teach classes as faculty members at nursing programs. Ms. Weston has been a preceptor for over five years at Wentworth Health Partners. In an interview with OnlineFNPPrograms.com, she described her responsibilities as a preceptor. “The tasks that a student takes on depend on if they are in their first or second year of clinical. First year students are mostly observing and asking questions. Second year students start to conduct interviews with patients and do clinical documentation,” she explained, “They will also see some patients for psychotherapy independently, documenting those visits. I am observing most of the visits a student will have with patients since they are unable to prescribe medications, so during those visits I can help in the clinical decision making process. I may ask more questions to help with this process, or lead the student in the right direction. When they see psychotherapy patients independently, we may discuss a care plan before the visit and then talk about the visit afterward.”
In addition to his clinical work at Kaiser Permanente, Mr. Penn is active in nursing education through several channels–as faculty member at the University of California, San Francisco School of Nursing, as a committee member for continuing education programs for psychiatric and mental health practitioners, and as a member of the American Psychiatric Nurses Association. “In the time that I have been working with Kaiser, I have also become extensively involved in teaching, earning an appointment as an Assistant Clinical Professor at the UCSF School of Nursing in 2009. Around that same time, I began working in continuing education for psychiatric nurses, psychotherapists, and psychiatrists, first serving on the steering committee of the Contemporary Forums Psychiatric Nursing Conference from 2009-2013 and have been on the steering committee of the US Psychiatric Mental Health Congress since 2010,” he said.
As a committee member for Contemporary Forums, Mr. Penn develops curricula delivered at national conferences, and as a faculty member for UCSF, he has taught on numerous topics within mental and behavioral health, psychotherapy, and improving psychiatric treatment outcomes. “I have taught on subjects ranging from bipolar disorder, improving treatment adherence, the risks and therapeutic potential of cannabinoids, and psychedelic-assisted psychotherapy,” he said.
The Rewards and Challenges of Psychiatric Mental Health Nursing
Psychiatric mental health nursing can be a very rewarding field for the concrete and dramatic positive impact that PMHNPs can have on their patients’ mental, emotional, physical, and social well-being. PMHNPs support people during some of their most vulnerable moments, when they are paralyzed by mental illness or behavioral patterns that are difficult to overcome, and difficult for those close to them to understand. As a result, the relationship between mental health practitioners and their patients can be a uniquely influential and rewarding one.
“By far, the most rewarding aspect of my work are the relationships I have with my patients. My patients allow me a window to their greatest vulnerabilities and trust me to partner with them to help them get better. This is a great privilege that I will never take for granted,” Mr. Penn told OnlineFNPPrograms.com in his interview, “I learn something new from patients all the time, and this allows me to get better at what I do.”
Mental, emotional, and behavioral health problems are often stigmatized in society, and additionally many health insurance companies prioritize coverage of physical ailments over mental health and behavioral health support. This lack of societal understanding often means that individuals struggling with mental health issues often find it difficult to seek social, familial, and professional support for their struggles. In her interview with OnlineFNPPrograms.com, Ms. Weston described this precise issue, and how her work to combat it as a PMHNP is the most gratifying part of her work with patients.
“The most rewarding aspect of my job is when patients get better. With the lack of access to providers and stigma that unfortunately still surrounds mental health diagnoses, I am often the first psych specialist that a patient sees,” she said, “Some are well into adulthood and have had symptoms throughout their lives. When we get the diagnosis and treatment right for people, they are so grateful. I have had many come back for follow up telling me they were able to go back to work, that they are having a more fulfilling time with their families, and were able to become social again. This is, by far, the greatest part of my job.”
Ms. Hickman noted to OnlineFNPPrograms.com that the empathetic and safe space that she provides to her patients to help them discuss and work through their psychological, emotional, and behavioral health problems has helped her to build rewarding and productive relationships. “One of the key attributes of a FPMHNP is listening to the client as much as possible. Despite limited time, it is still imperative for the client to feel that you understand what their struggles have been,” she said, “This then allows the provider to start to build the relationship between the client and themselves and allows for forward progression and ultimately, reaching treatment goals. […] Working as a PMHNP has been so rewarding. Some of my clients have just gotten insurance and so have been struggling for months or years.”
In addition to the impact they have on their patients and the rewarding relationships they form with patients and their families, PMHNPs may find the relationships they form with the colleagues to be fulfilling as well. “The next most rewarding thing about my profession is the collegiality that I encounter with my fellow professionals,” Mr. Penn said, “Some of the brightest, most compassionate, most intelligent people I have ever met are fellow mental health professionals, and I feel fortunate to work with them to help our patients heal (when I am in the clinic) and to help our colleagues and students hone their skills (when I am in the classroom or on the conference stage).”
Challenges of the profession include coming up against barriers to getting patients the medical and psychological support they need, whether those barriers are lack of insurance coverage or a patient’s own preconceptions about taking medication or the types of medication he or she should take. “Sometimes we deal with lack of compliance with treatment. Sometimes there is lack of family support, which leads to noncompliance,” Ms. Weston noted in her interview, “Specifically with my current position, I have to work in concert with primary care and there are often disagreements about medications and treatment. That can be challenging too.”
For their patients who are suffering from more severe psychiatric conditions, one challenge PMHNPs may encounter is ensuring that their patients receive the intensive care they need in a timely fashion. Ms. Weston elaborated on this difficulty as well in her interview. “One of the biggest problems in my area is inability to get patients hospitalized when they need to be. PMHNPs and psychiatrists are not able to directly admit patients to a hospital in most outpatient settings, no matter how much we feel they need to be there. They have to go to the ER to be evaluated, and many times are sent home. […] It is frustrating and sometimes unsafe.”
The barrier to getting patients experiencing acute psychiatric symptoms admitted to the hospital is generally tied to lack of resources, such as a shortage of beds or staff to care for patients. Ms. Weston noted that she tries to manage this barrier by being clear and persistent with emergency care services when she does need to send a patient to a facility for hospitalization. “The way I have dealt with this is by making sure I present my reasons for wanting a patient admitted in writing. If I send a patient to the ER for evaluation, I always call to let the staff know they are coming and that I will be sending my office note for both them and the evaluator to review,” she said, “I state in my note reasons why I believe they may be a danger to themselves and others, and that my recommendation is hospitalization. This has been successful in getting patients the treatment they need much of the time.”
Advice on Becoming a Psychiatric Mental Health Nurse Practitioner
The complex and at times severe nature of the health problems their patients experience, and the equally complex and delicate nature of psychiatric treatment and psychotherapy means that PMHNPs must undergo rigorous training in order to provide safe and effective care to their patient population. Prospective PMHNPs must earn certification through the American Nurses Credentialing Center in order to practice, and also research and obtain any state-specific licenses and credentials necessary to practice in their state of residence.
To be eligible for ANCC certification as a Psychiatric Mental Health Nurse Practitioner, registered nurses must complete a graduate nursing program in advanced psychiatric mental health nursing from an institution that has been accredited by either the Commission on Collegiate Nursing Education or the Accreditation Commission for Education in Nursing, and complete a minimum of 500 clinical practicum hours through this program. The completion of foundational classes in advanced physiology and pathophysiology, advanced health assessment, advanced pharmacology, and differential diagnoses and disease management are also required in order to be eligible for the ANCC certification examination.
Registered nurses who are interested in becoming PMHNPs should try to gain as much exposure to the work environments in which PMHNPs work prior to entering the field, in order to gain a better understanding of, not only their personal professional interests, but also how mental health problems progress and can escalate without early and consistent treatment. Seeing both the outpatient and inpatient sides of psychiatric mental health nursing can help PMHNPs better understand the treatment difficulties that their patients encounter, which can help them better support patients in either setting. In her interview with OnlineFNPPrograms.com, Ms. Weston explained how her clinical practicum work in an inpatient psychiatric unit helped her to serve her patients better upon graduation. “My best advice for someone thinking about working in advanced practice psychiatric nursing would be to get some experience in the field either prior to applying to graduate school or during the process. I worked on a psychiatric unit while I was in graduate school. I actually didn’t like the setting. At the same time, I was doing clinical internships in outpatient settings,” she explained, “I was able to see that I would be much better suited to working in the outpatient world. Working in the hospital setting, I was able to see what happens when those patients I was seeing in the outpatient world get very sick. I think it was important to see what that looked like.”
In addition to getting experience in a broad range of psychiatric settings during their graduate nursing program, students should also work to gain a solid understanding of human anatomy and physiology as well as human psychology and pharmacology, and to see how physiology, psychology, and pharmacology connect in patients’ mental health struggles over time. “Get a solid foundation in the sciences. If you don’t understand anatomy, physiology is going to be hard for you because it will be like being given directions through a city without a map. If you don’t understand what normal physiology is, you won’t be able to grasp pathophysiology. Pharmacology is going to be difficult if you don’t understand basic chemistry. Work hard and learn as much as you can in these fundamental classes,” Mr. Penn recommended.
Volunteering outside of one’s clinical internships can also provide useful experiences and networking opportunities for prospective PMHNPs. “I think having a good nursing background in med-surg nursing and gaining experience with inpatient stay would be extremely helpful. Volunteering at long-term care facilities or pre-schools to gain experience working with all ages in their habitats will prepare the student to help determine what they would like to specialize in,” Ms. Hickman noted in her interview.
Upon completing their graduate nursing program, RNs should prioritize preparing for their certification examinations and consulting their state board of nursing regarding additional credentials they need to obtain in order to work in their desired field of advanced psychiatric nursing. “Becoming board certified in a specialty will help with the job search and salary potential. As far as becoming board certified I would recommend any of the study materials that are out there. I got the CDs and listened to the lectures and then went on the ANCC website and took practice exams,” Ms. Hickman said.
Mr. Penn advised that nursing students and practicing nurse practitioners take care of their own physical, mental, and emotional health in order to maintain resilience on the job and prevent job-related injuries. “If you’re working in a hospital, and doing the hard physical work of lifting and moving immobile patients, start working out with weights and get strong,” he advised, “Many nurses by the middle to end of their careers have incurred chronic back injuries. Don’t be one of them.”
Above all, nursing students training to become psychiatric mental health nurse practitioners should proactively seek opportunities to challenge themselves and learn as much as possible by being receptive to constructive feedback and impromptu mentorship opportunities. “Seek out mentors who have been in the field for a while and avail yourself of their experience. Learn to ask intelligent questions from them. Learn how to take feedback without getting defensive. No one likes to be corrected, but when you’re a student, you should expect to be corrected, otherwise, why are you there?” Mr. Penn pointed out, “See your ignorance as an opportunity, not a liability.”
Mr. Penn also encouraged nursing students interested in psychiatric mental health nursing to view becoming a PMHNP as a constant process of learning that extends beyond the school setting. “Get curious and stay curious. Go deep into your subjects. Learning should be exciting, not a chore. If you can master this mindset, you will excel at all that you take on.” Through diligent preparation, a strong work ethic, an eagerness to learn, and sufficient clinical experience, prospective PMHNPs can build an impactful and fulfilling career helping underserved and vulnerable patient populations receive the care they need.
- “Medical Necessity and Level of Care Determination Criteria,” priorityhealth.com, Priority Health, https://www.priorityhealth.com/provider/manual/auths/bh/~/media/documents/bh/bh-medical-necessity-criteria.ashx
- “Levels of Mental Health Care Descriptions (Lowest to Highest),” cignabehavioral.com, Cigna Behavioral Health, apps.cignabehavioral.com/cignabehavioral/media/consumer/educationAndResourceCenter/articles/levelsOfMentalHealth.pdf
- “Understanding Psychological Testing and Assessment,” apa.org, American Psychological Association, http://www.apa.org/helpcenter/assessment.aspx