POSITION STATEMENT: Psychiatric-Mental Health Nurses’ Role in Primary Care

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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. Acknowledging that PMH-advanced practice registered nurses (APRNs) are primary care providers and PMH-registered nurses (RNs) are essential members of the primary care team is crucial to the comprehensive treatment of individuals. This acknowledgement is also vital to the development of a workforce that can effectively manage coexisting physical and mental health disorders to meet the growing needs of the population.

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 tophysical 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

Psychiatric-Mental Health Registered Nurses are key members of a primary care team. According to the Psychiatric-Mental Health Nursing: Scope and Standards of Practice, psychiatric-mental health nurses work in a variety of settings across the continuum of care to promote mental health “through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the lifespan” (ANA, APNA, ISPN, 2014, p.19). They work with persons experiencing “physical, psychological, mental, and spiritual distress” (p. 19) and, in addition to psychiatric-mental health care, psychiatric-mental health RNs “provide basic care and treatment, general health teaching, health screening, and appropriate referral for the treatment of general or complex physical health problems” (p.20). Working with a primary care provider, such as an advanced practice nurse, PMH-RNs offer essential services that contribute to meeting personal health needs, as stipulated in the Institute of Medicine’s (1996) definition of primary care.

Psychiatric-Mental Health Advanced Practice Nurses are primary care providers. Psychiatric-mental health APRNs are educated, licensed, and certified as primary care providers with a population focus of psychiatric-mental health. This is supported by the following:

  • PMH-APRN Education
    The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education (Consensus Model) has been adopted by 48 national nursing organizations as the guiding structure for the advanced practice nursing (APRN) profession. The model identifies six population foci for APRN (CRNA, NP, CNS, CNM) education: family/individual across the lifespan, adult-gerontology, neonatal, pediatrics, women’s health/gender-related, and psychiatric-mental health. Under the National Organization of Nurse Practitioner Faculties’ (NONPF) Nurse Practitioner Core Competencies (2012), all APRNs, regardless of their population focus, are educated in nine core competencies, including the delivery of all aspects of primary care (NONPF, 2012).
     
  • PMH-APRN Licensure and Certification
    PMH-APRNs (PMH-NPs or PMH-CNSs) are licensed and certified at the population focus level and not at a specialty level. They are certified in a primary care focus (AANP, 2020) and are therefore primary care providers “prepared to fulfill the definition of primary care across settings, including the provision of care at first contact for undifferentiated conditions, ongoing management of acute and chronic conditions, health promotion and care coordination” (AANP, 2013). The American Nurses Credentialing Center, who provides board certification to PMH-APRNs, states that the Psychiatric-Mental Health Nurse Practitioner (Across the Lifespan) Certification (PMHNP-BC) “aligns with the Consensus Model” (ANCC, 2020, para. 1), affirming that board certification for PMH-APRNs is as a primary care provider with a population focus in PMH. Further, the National Council of State Boards of Nursing’s NCSBN Model Act (2012), states that an APRN may serve as primary care provider of record for populations including psychiatric-mental health.


PMH-APRNs deliver “primary care services, which include the diagnosis and treatment of common health problems...and, given their unique skill set and clinical training, primary care PMH-APRN practice will only expand in the next decade” (ANA, APNA, ISPN, 2014, p. 31). PMH-APRNs deliver these primary care services in both psychiatric-mental health settings and in settings more traditionally recognized as primary care such as family medicine, internal medicine, pediatrics, obstetrics and gynecology, prisons, home health care, and hospitals. Using a range of skills to provide care for both the mind and body, PMH-APRNs conduct comprehensive physical exams and must have command over multiple scientific bodies of knowledge including medical science, nursing science, neurobiology of psychiatric disorders, evidence-based practice (EBP) treatment methods, and relationship science to fulfill their role of promoting optimal mental and physical health and wellbeing (ANA, APNA, ISPN, 2014).

Conclusion

Access to whole-person primary care that promotes physical and mental well-being will reduce costs and promote better outcomes through prevention and early intervention. 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 care for the growing population of persons with mental health and substance use needs.

Approved by the APNA Board of Directors February 23, 2013.
Revised and approved by the APNA Board of Directors July 14, 2020.


 


References
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American Association of Nurse Practitioners (AANP). (2020). NP fact sheet. https://www.aanp.org/about/all-about-nps/np-fact-sheet

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American Nurses Credentialing Center (ANCC). (2020).https://www.nursingworld.org/our-certifications/psychiatric-mental-health-nurse-practitioner/

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National Council of State Boards of Nursing (NCSBN). (2012). NCSBN Model Act. https://www.ncsbn.org/14_Model_Act_0914.pdf

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U.S. Department of Health and Human Services & Office of the Surgeon General (2016). Facing addiction in America: The Surgeon General's report on alcohol, drugs, and health.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis (HRSA). (2016). National projections of supply and demand for behavioral health practitioners: 2013-2025. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, National Center for Health Workforce Analysis (HRSA). (2018). State-level projections of supply and demand for behavioral health occupations: 2016-2030. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/state-level-estimates-report-2018.pdf

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