18 minute read
SPECIALTY SPOTLIGHT: PSYCH-MENTAL HEALTH
Mental health in America dramatically worsened with the onset of the pandemic. In 2019, about one in 10 adults reported symptoms of anxiety or depression. By 2021, two in five reported symptoms with other negative impacts on mental health, such as increased substance use and worsened chronic conditions from added worry and stress. The surge in mental illness shined a spotlight on the country’s mental health state and the shortage of health care providers trained to offer proper care to those who need it.
While solving such a crisis requires time and resources, there is no question that psychiatric-mental health nurse practitioners (PMHNPs) play a key role in expanding the number of mental health practices throughout the country and providing telehealth services to those who cannot get these services in person. In the U.S., fewer than 5% of the more than 355,000 licensed nurse practitioners are certified in psych-mental health, but more nurses are choosing this specialty, says Lee Tyson, DNP, DMin, MDiv, APRN-CNP, PMHNP-BC, ANP-BC, CARN-AP, FIAAN, associate professor of clinical and director of UC’s PMHNP programs.
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“We have seen a huge demand for our psych-mental health programs from advanced practice nurses who want to be dually certified. The culmination of bad things happening, coupled with the realization that mental wellness is part of overall wellness, brought psych-mental health nursing to people’s radars,” Tyson says. “Many nurses feel meeting their patients’ emotional needs is already part of their job, so why not learn how to do it in the best way possible?”
For Tyson, nursing is a second career. He has graduate degrees in ministry and theology and worked as a clergyman for more than a decade, but ultimately others would not accept how he reconciled his faith with his sexual orientation. To live authentically and support his husband and three children, Tyson entered UC’s accelerated nursing program, earned his bachelor’s in 2008, master’s in adult primary care in 2010 and doctorate in psych-mental health in 2013. Along with his position at UC, Tyson also serves as owner and CEO of Lee Side Wellness, an outpatient mental health clinic he founded in 2016.
PMHNPs assess, diagnose and treat the mental health needs of patients. Many provide therapy and prescribe medications for patients who have mental health or substance use disorders and may also provide physical and psychiatric assessments, emergency psychiatric care and treatment effectiveness evaluations. The patient population treated by these providers includes children, adolescents, adults and older adults in settings such as primary care facilities, hospitals, residential care facilities, behavioral health clinics, inpatient treatment facilities and correctional facilities.
“The main difference between PMHNPs, psychiatrists and psychologists is that we are prepared to assess our patients holistically and treat the whole person. We are nurses first, so we look at each patient’s emotional, physical, existential and spiritual needs,” Tyson says. “Patients don’t leave their pre-existing health problems at home when they have a mental health crisis, so PMHNPs need finely tuned, specialized assessment skills to support patients with severe mental illness in efforts toward health.”
Registered nurses who want to work as PMHNPs must earn a graduate degree in the specialty and get licensed by the American Nurses Credentialing Center (ANCC). UC offers two paths to become a PMHNP — a post-master’s certificate, designed for nurses who already hold a graduate degree, and a Doctor of Nursing Practice (DNP) for bachelor’s-prepared nurses. Both programs prepare students to care for the mental and physical well-being of people with mental health conditions or behavioral problems, but the DNP — the terminal degree in nursing practice — equips nurses to promote evidence-based practice and leverage systems leadership and quality improvement processes to design programs of care delivery that are functional, economically feasible and significantly impact patient outcomes.
“In both programs, faculty feel most accomplished when students are successful. Our faculty — all practicing clinicians who bring real life clinical experiences to the classroom — understand life happens,” Tyson says. “Our expectations are high, but we are sensitive to the fact that our students have a lot going on in their lives.”
As a better-understood, much-needed, fast-growing specialty that offers plenty of well-paid job opportunities, the PMHNP path has become a popular choice for nurses. But, Tyson says, it’s not for everyone.
“There are plenty of opportunities for jobs, especially for students who graduate from a reputable school like ours. People are attracted to the PMHNP role for many different reasons but, at some point, may realize they are not cut out for it,” Tyson says. “It is not you who chooses to become a PMHNP; rather, it chooses you. It is truly a calling, a specialty you take home with you.”
To get a deeper understanding of the specialty, we asked four UC alumnae about their journey before and after becoming PMHNPs: Kelsey Holstein (KH), who graduated in the spring with her DNP; Tulsi Majchrzak (TM) and Becky Spencer (BS), who earned their post-master’s certificates in 2021; and Summer Wilson (SW), who earned her post-master’s certificate in 2019.
Please share a little about your educational and professional background before becoming a PMHNP.
KH: I graduated with my Bachelor of Science in Nursing (BSN) in 2014 and began working as a new graduate nurse at Fairview Hospital, which is associated with the Cleveland Clinic in Cleveland, Ohio. I worked on a heavily surgical unit taking care of patients before orthopedic and gastrointestinal surgeries. After about a year, I left Ohio for a community hospital bedside nurse job in San Diego, California. There, I worked on a unit focused on illnesses such as uncontrolled diabetes and various infections. I remained at that job throughout my PMHNP program at UC.
TM: I always knew I wanted to work with individuals with mental health disorders. Becoming a psychiatric nurse was my goal when I decided to attend nursing school. After completing my BSN, my first job was a charge nurse on a dual diagnosis unit at Friend’s Hospital, one of the oldest psychiatric hospitals in our nation, located in Philadelphia, Pennsylvania. After some time, I earned my master’s degree in nursing education and worked as a clinical instructor at the University of Pennsylvania School of Nursing, teaching psychiatric nursing to junior nursing students in both stimulation and clinical settings.
BS: I have worked in many nursing specialties over the past three decades, but my real passion is caring for families in the perinatal period. I have been a lactation consultant for 18 years
Lee Tyson, DNP, DMin, MDiv, APRN-CNP, PMHNP-BC, ANP-BC, CARN-AP, FIAAN
– Lee Tyson, DNP, DMin, MDiv, APRN-CNP, PMHNP-BC, ANP-BC, CARN-AP, FIAAN
and completed my PhD in 2012. My research trajectory centers on breastfeeding in vulnerable populations. My second passion is teaching nursing; I have held a faculty position for the past 12 years, and I currently teach at the graduate programs at Texas Woman’s University.
SW: After getting my BSN, I got a master’s degree in midwifery. I maintained a home birth practice from 2005-2012 and, when I stopped practicing, I worked at Passport Health doing international travel education and vaccination.
Why did you decide to become an PMHNP?
KH: I always had an interest in psychology and psychiatry and considered pursuing the pre-med program during my undergraduate education with the goal of becoming a psychiatrist, but I knew I could work as a nurse practitioner specializing in psychiatry, so I stuck with nursing and obtained a minor in psychology. However, it was really my job as a hospital bedside nurse that solidified my focus on psychiatry, as I often saw that patients were unable to manage their physical health because of undiagnosed or mismanaged mental health issues. It’s hard to learn about and manage diabetes or high blood pressure when there are voices in your head or you’re so depressed you physically can’t get out of bed. We can’t see mental illness — it’s not tangible in the same way that physical illness is — so the perception surrounding mental illness is vastly different. Even in 2022, there’s still stigma surrounding mental illness, significant access issues and other barriers. If I can affect even a small number of people or reduce stigma and barriers, my career will be purposeful and meaningful for me.
TM: I decided to go back to school for my PMHNP post-master’s certificate because I wanted to expand my knowledge about psychiatric nursing and practice as a provider. I loved teaching my students, but I missed having direct patient interactions and providing care. I knew that going back to school for my nurse practitioner degree was something I wanted to do because I have worked with psychiatric patients in some capacity throughout my nursing career and I have found it to have a positive impact on both me as a professional and on my patients. I believed I would be doing myself an injustice if I did not pursue my PMHNP license and practice in a field where I know I can make a positive impact.
BS: When I finished my PhD, I think my family was ready for me to be finished with being a student, but I believe being a perpetual student makes you a relevant and humble teacher. Perinatal mental health was the giant elephant in the middle of my research and clinical work, and I was frustrated with the lack of resources in my area and lack of providers who were specialized in treating perinatal mental health illnesses. The incidence of depression and anxiety disorders that occur in the perinatal period has increased significantly in recent years, and untreated or undertreated mental illness has short- and long-term detrimental health consequences for parents and children. That is why, in 2020, I decided to take a leave of absence from teaching to pursue a PMHNP post-master’s certificate. SW: I have always had a personal interest in psychology. I was considering going back to school to become a psychotherapist until I figured out that PMHNPs do therapy in combination with medication management.
How do you feel UC College of Nursing prepared you for what was ahead in your specialty?
KH: I grew up in Ohio, so I was aware of UC College of Nursing’s great reputation. When I started browsing programs, UC showed up as one of the best online graduate nursing programs. Now that I’ve graduated, I can confidently say the college deserves the reputation and rating it carries. From the start to the end of my program, I had nothing but great classes and professors. When COVID hit, I didn’t know what to expect (like most of the world), but UC faculty and administrators made sure we were supported as we navigated the pandemic. One of my most influential professors was Dr. Susan Brammer, who chaired my doctoral project. She guided me through my entire project (with many ups and downs) and through my application to present at the American Psychiatric Nurses Association’s annual conference; I’ll be presenting a poster there in October! Through UC, I learned how to be a high-quality psychiatric-mental health nurse practitioner, but also how to be a nursing leader.
TM: UC’s PMHNP program has prepared me well with the knowledge and skillset to practice confidently as a mental health provider. UC provides its students with the knowledge, skills and attitude needed to be a successful practitioner. The college provides classes that rigorously delve into essential content matter in the areas of medication management and psychotherapy for various psychiatric diagnoses across the lifespan. Clinical time with a mentor is required, which supports theoretical coursework and aids in converting knowledge to practice. My favorite aspect of this program was the faculty and the plethora of knowledge and expertise they possess as educators and clinicians. They are also very kind and approachable; they would go the extra mile for their students if a topic was not understood or more resources were needed. I have always felt supported in my studies. Several faculty members are mental health advocates and their contributions to the community are truly inspirational. UC shapes its students to follow in the same footsteps and become leaders in the nursing profession.
BS: UC’s program prepared me quite well. I graduated in August 2021, passed the American Nurses Credentialing Center board exam, received my licensure by the end of 2021 and started working in a comprehensive perinatal mental health program in January 2022. The coursework prepared me to take board exams, and I really enjoyed learning both from my instructors in the program and my classmates. The job prospects for PMHNPs are plentiful and well-paid. SW: I had no background in psychiatric nursing, so I felt like I was starting from scratch. I worked very hard, did all required readings and work and got lucky enough to have a wonderful preceptor, Dr. Lee Tyson. It helped that I was very interested in the subject matter and wanted to learn all I could about it.
Kelsey Holstein
Tulsi Majchrzak
Becky Spencer
Summer Wilson
In what type of community and setting have you practiced?
KH: My nursing practice has always been in urban areas: Cleveland and San Diego. In Cleveland, my hospital was approximately 15 minutes from downtown, so we did see a wide range of age, race and socioeconomic states. San Diego has an incredibly diverse population, and I have encountered people from all walks of life coming from all over the world. Recently, I accepted a telehealth position within a private practice as a PMHNP serving patients in a variety of areas in Colorado and Massachusetts. There will be a significant degree of diversity in this population, and I’m excited to be challenged in new ways.
TM: While I was working as an inpatient psychiatric nurse and clinical instructor, I practiced in an urban setting. Now that I practice using a telehealth platform, I see patients from various communities with different levels of income. I believe working with such a diverse population of patients is one of the neat parts of telepsychiatry.
BS: I work for a community mental health clinic in Texas providing comprehensive mental health treatment to parents who experience perinatal mental health illnesses. I work with a wonderful team of therapists and nurses who are all passionate about perinatal mental wellness and clinical collaboration.
SW: Since graduation, I worked at an addiction center, and then I started at a company doing 100% telepsychiatry in three states. Last December, I started working at an outpatient practice and mostly see children and teens both in person and virtually.
What are your daily and long-term responsibilities as a PMHNP?
KH: As a PMHNP, I assess, diagnose and treat patients with a variety of mental illnesses. As PMHNPs, we can prescribe medication, but when working to improve mental health, medication is only one part of the recovery plan. Some level of therapy or counseling is typically beneficial to most clients. It’s hard to build up coping mechanisms and other stressreduction tools during times of crisis, so taking the time to learn and grow these skills during the recovery process is important. Another huge aspect of the PMHNP role is psychoeducation. I’m responsible for educating my clients about their diagnoses, as well as various treatment options and the risks/benefits of those options. Some of the long-term responsibilities include advocacy for clients, as well as mental health care as a whole, working to change outdated policies and acting as a mentor for other PMHNPs.
TM: As a PMHNP working in telehealth, my daily responsibilities include conducting clinical assessments, prescribing psychotropic medications and conducting talk therapy. I collaborate with the interdisciplinary health care team to discuss patients’ goals and plans of care and monitor their progress. Some of the medical services I am responsible for include monitoring lab work and vital signs, as well as assessing for adverse medication reactions, such as serotonin syndrome, neuroleptic malignant syndrome and various types of extrapyramidal symptoms, and intervening accordingly.
BS: I provide medication management and psychotherapy for patients in a behavioral health partial hospitalization and intensive outpatient setting. Our patients spend three to four hours per day, Monday through Friday, in psychotherapy, and I see our patients for medication management twice per week. I have seen great strides toward wellness in four to six weeks of collaborative and intensive psychiatry and psychotherapy treatment. I also see patients in private practice — typically
once every one to three months — for medication management and psychotherapy. Another important long-term responsibility of all nurse practitioners is to support and get involved with state and national nurse practitioner associations. Our voices are stronger together and our professional organizations help to raise our voices to garner support at the state and national levels for the ability for all nurse practitioners to practice at the full extent of our licensure.
SW: I consider building a strong relationship and trust with my patients as my primary role. Although I do medication management, there is also a bit of psychotherapy involved. There are also lots of administrative tasks, including communicating with patients over texts and emails, managing referrals and communication with other providers involved in the patient’s care, finishing charts, putting in prescriptions, completing referral forms for patient programs and FMLA paperwork.
What have been some of the most rewarding and challenging aspects of working as an PMHNP?
KH: One of the most rewarding aspects is seeing clients move through recovery. In psychiatry, recovery doesn’t mean cure, but more so that symptoms are better managed and the quality of life of the client is improved. Mental health exists on a spectrum, so recovery is a lifelong process with inevitable ups and downs, but ideally the downturns are less severe as the client moves through treatment. It’s also very satisfying to see clients apply what they’ve learned; they get better at identifying triggers as well as coping mechanisms and this helps them develop some autonomy within the recovery process. Some of the challenges include funding and access to mental health care. According to the National Alliance on Mental Illness, only 45% of adults with mental illness receive treatment, which means more people are suffering than are being treated. We need improved access to care and improved funding for programs to reach more people.
TM: I find working as a PMHNP a very rewarding career. I consider it humbling when patients are vulnerable and open up about their feelings and emotions. Many times, the population of patients I treat does not have a support system, so I find it meaningful to offer my assistance at such a difficult time in their lives. As in any field of nursing, there can be several challenges — patients can be non-adherent with their medication regime and, unfortunately, this can cause their mental health to deteriorate. Ensuring that patients adhere to their discussed treatment plan is crucial in obtaining positive outcomes and achieving treatment success. It is essential to continuously provide medication education, stress the importance of treatment compliance and ensure the patient is comfortable and has faith in you as their provider.
BS: One of the biggest challenges in Texas, the state where I practice, is insurance reimbursement and the cost of mental health care. Many insurance plans have higher copays or less coverage for mental health provider visits than for other medical visits, which prices mental health care out of the reach of many patients. The complexity of insurance billing has resulted in many psychiatric providers only accepting cash pay for care, which also limits access to mental health care for many patients. Another challenge is the Texas state requirement that advanced practice nurses have a contract with a collaborating physician. States with limited practice laws continue to cause many barriers for nurse practitioners’ practice. These collaboration agreements have a high cost for nurses and do little to promote high-quality and safe patient care.
One of the biggest rewards of my work as a PMHNP is seeing patients get better. I can truly say that treatment works and it works best when medication management and psychotherapy are closely collaborated. Another reward is being able to provide the level of care that patients need. The need for mental health care greatly exceeds the number of available providers. Prior to becoming a licensed PMHNP, I was limited in my ability and scope of practice as an RN to provide the mental health treatment so many of my patients needed. Now, I am helping to narrow the gap in the delivery of evidence-informed mental health care.
SW: It is very rewarding when a patient comes back and says you have changed their life for the better. Some challenges include finding a collaborative physician, struggling to get insurance reimbursement and spending so much extra time doing administrative tasks.
– Tulsi Majchrzak, MSN, PMHNP-BC
