APNA Position: Psychiatric-Mental Health Nurses’ Role in Primary Care 

Introduction

Psychiatric-mental health (PMH) nurses use an essential body of knowledge and skillset to provide ‘whole person’ care to address a range of common health problems, across health settings. Supported by their education and licensure, (PMH) nurses not only treat illness, but also partner with their patients to help them achieve their own recovery and wellness goals. With emerging models of care and provider shortages, patient populations have the majority of their health needs met in a variety of settings, including integrated care and behavioral health clinics. It is APNA’s position that PMH-advanced practice registered nurses (APRNs) are primary mental health care providers and PMH-registered nurses (RNs) are essential members of the primary mental health care team.

Background

The Institute of Medicine’s report, Primary Care: America’s Health in a New Era (1996), defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community” (IOM, 1996, p. 1). This definition of primary care recognizes the need to integrate services and that primary care should address most of an individual’s health care needs. This means that primary care occurs in a variety of settings, depending on patient needs and provider services, including in psychiatric-mental health settings.

Mental health and substance use disorders are among the most common disabling health problems worldwide and contribute to the presenting complaint in a high proportion of care visits. The complex physical and mental health needs of persons with serious mental illness and/or substance use disorders are well recognized – the majority of patients with psychiatric-mental health and substance use disorders also experience comorbid medical illness. Mental health and physical health are linked – mental health is foundational to physical health, as it fosters the ability for people to build and strengthen, in partnership with health care providers as needed, their own long-term physical health and well-being (APNA, 2020). Further, a wealth of scientific evidence shows that the separation of mental health and substance use services from “mainstream” care causes significant issues in care coordination (HHS, U.S. Surgeon General, 2016).

The Future of Nursing: Leading Change, Advancing Health (IOM, 2010), which was adopted as an official APNA position in 2015, states that all nurses should “should practice to the full extent of their education and training” (para. 3). The education and training of psychiatric-mental health nurses provides them with command over “multiple bodies of knowledge (medical science, neurobiology of psychiatric disorders, treatment methods, and relationship science)” (ANA, APNA, ISPN, 2014, p.17), which positions them as providers who are able to connect services and address gaps in care across the spectrum of the psychiatric-mental health and/or substance use disorder population’s multiple health care needs.

Discussion

The following excerpts from the Psychiatric-Mental Health Nursing: Scope and Standards of Practice (ANA, APNA, ISPN, 2022) support this position:

“Nurses, and specifically PMH nurses and PMH advanced practice nurses, are important contributors to successful behavioral and primary care integration teams (Delaney et al., 2018).” (p.36)

“PMH nurses function across all settings where individuals with mental health issues or psychiatric disorders are found. These settings include psychiatric inpatient units, emergency departments, medical-surgical units, outpatient clinics, community health care centers, primary care offices, schools, and jails and prisons.” (p.40)

“The roles for PMH-APRNs who practice in primary care settings include but are not limited to (a) collaboration and consultation with other primary care provider partners from other disciplines, (b) direct provision of behavioral health care in integrated primary care settings, and/or (c) direct provision of behavioral health care within health service sites that have been referred to as reverse colocation models (Brown, Moore, MacGregor, & Lucey, 2021).” (p.45)

“An important issue … involves how primary care is currently conceptualized, which, in turn, influences how the integrated care workforce is defined and how its training is supported. This workforce crosses traditional primary care and behavioral health care lines. Restrictive definitions of primary care (e.g., primary care is the first point of contact residing in one of five specialty areas) limit the boundaries of the primary care workforce and perpetuate a mind-body split. A comprehensive conceptualization of primary care that fits with the current expansion of services is found in an earlier definition of primary care forwarded by the IOM (1994):

Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (p. 1)

This definition creates more appropriate boundaries for the integrated care models that reside in both traditional primary care and expanded behavioral health care settings. As the conceptualization of primary care broadens to accommodate integrated care, it is clear that PMH advanced practice nurses are, by this definition, already delivering primary care services, which include the diagnosis and treatment of common health problems (APNA, 2020). Given their unique skill set and clinical training, PMH-APRN practice in primary care settings will only expand in the next decade. PMH-APRNs who are able to work at their full professional capacity will be invaluable resources for bridging the gap of needed behavioral health services in primary care settings.” (p.46-47)

Conclusion

Access to whole-person primary care that promotes physical and mental well-being will reduce costs and promote better outcomes through prevention, early intervention, assessment, and treatment. As this understanding drives evolving models of care and efforts to enhance access to that care, it is essential that psychiatric-mental health nurses be recognized as a workforce that is educated, trained, and licensed to provide primary care to the psychiatric-mental health population. Additionally, the PMH-APRN workforce should have the ability to practice to the full extent of this education and training. This will promote better outcomes, reduce health disparities, and increase access to primary mental health care for the growing population of persons with mental health and substance use needs.

Approved by the APNA Board of Directors February 2013
Revised July 2020; Revised June 2022

References

American Nurses Association (ANA), American Psychiatric Nurses Association (APNA), & International Society of Psychiatric Nurses (ISPN). (2022). Psychiatric-mental health nursing: Scope and standards of practice (3rd ed.).