Survey to child/adolescent psychiatry and developmental/behavioral pediatric training directors to expand psychiatric‐mental health training to nurse practitioners

Richard H. Schwartz, MD, FAAP, FPIDS (Pediatrician), Mary C. O’Laughlen, PhD, RN, FNP-BC, FAAAAI (Former Assistant Professor), & Joshua Kim, BA (Medical Student and Research Assistant)​​​​​

Journal of the American Association of Nurse Practitioners


Introduction

Between 16% and 20% of children living in the United States experience a mental health disorder in any given year (Centers for Disease Control and Prevention, 2013). There is a chronic shortage of board‐certified child/adolescent psychiatrists (CAPs) available to see nonhospitalized children with mental health issues. There is also an acute shortage of developmental/behavioral pediatricians (DBPs). This mismatch between need and supply is a problem that is particularly acute in many areas of the United States where the poor and rural population live (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2014). Workforce analysis shows that there will continue to be a serious shortage of CAPs well into the future. The demand for the services of child and adolescent psychiatry is projected to increase by 100% between 1995 and 2020 (U.S. Department of Health and Human Services, 2006). As the shortage of psychiatrists and the increasing need for mental health care have been noted, several solutions to bridge this ever‐widening gap have been advocated, but one suggestion to help alleviate this shortage is through nurse practitioners (NPs). Other suggestions have included the use of telemedicine to reach underserved areas (Japsen, 2016), increasing the number of child and adolescent psychiatrists (American Academy of Child Adolescent Psychiatry, 2016), and four states have currently granted prescriptive authority to psychologists (American Psychological Association, 2016). All these suggestions will most likely be needed to meet the current workforce shortage.

The purpose of this survey was to ask the directors of both CAP and DBP training programs about their receptivity and willingness to provide additional training for NPs who provide care to children with mental health issues and to examine the main obstacles to the development of such programs.

Background and significance

Health Professional Shortage Area (HPSA) designations are used to identify areas and population groups within the United States that are experiencing a shortage of health professionals. Currently, there are approximately 4000 mental HPSAs nationwide (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2016). The primary factor used to determine an HPSA designation is the number of health professionals relative to the population with consideration of high need. Federal regulations stipulate that to be considered as having a shortage of providers, an area must have a population‐to‐provider ratio of a certain threshold. For mental health, the population‐to‐provider ratio must be at least 30,000:1 (or 20,000:1 if there are unusually high needs in the community). For example, when there are 30,000 or more people per psychiatrist, an area is eligible to be designated as a mental HPSA. Applying this formula, it would take approximately 2800 additional psychiatrists to eliminate the current mental HPSA designations nationally (Association of American Medical Colleges, 2016). In Virginia, Maryland, and the District of Columbia, approximately 34%–40% of the residents of these three states currently have mental health needs that are not being met (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2016). There are approximately 8300 practicing child and adolescent psychiatrists in the United States (American Academy of Child and Adolescent Psychiatry, 2016).

Education for NPs in psychiatric/mental health has taken several paths. Previously, Clinical Nurse Specialists could also be certified in psychiatry‐mental health but their numbers have been declining steadily since 2005 and the last application for both the adult psychiatric–mental health and the child/adolescent psychiatric–mental health clinical nurse specialist examinations was December 31, 2016 (American Association of Nurse Practitioners, 2016; Jones & Minarik, 2012).

After graduation from a family (FNP) or pediatric nurse practitioner (PNP) program, the few graduates who wish to go beyond their training and concentrate in child and adolescent behavior and mental health are typically trained on the job by a CAP and/or experienced mental health NP mentors. FNPs and PNPs who do additional mentored training in pediatric psychiatric and behavioral disorders continue to function under their respective certifications.

There is a postgraduate certification available as an elective option for advanced practice registered nurses (APRNs), the Pediatric Primary Care Mental Health Specialist (PMHS) certification (Hawkins‐Walsh & van Cleve, 2013; Melnyk et al., 2010). The PMHS exam is a secondary certification through the Pediatric Nursing Certification Board for APRNs that requires a minimum of 1000 h of APRN primary care behavioral/mental health clinical practice experience within the past 2–3 years and is maintained through completing continuing education contact hours every 3 years (Pediatric Nursing Certification Board, 2016).

Resources have been created to assist NPs who want to develop further their primary mental health skills after they enter practice. Two examples are the Keep your children/yourself Safe and Secure (KySS) online Child and Adolescent Mental Health Fellowship (Ohio State University College of Nursing, 2016), or the Reach Institute workshops (Ohio State University College of Nursing, 2016; The Reach Institute, 2015). These programs combine didactic teaching with ongoing follow‐up support for clinicians, usually by telephone conferencing.

Because there were no developmental‐behavioral pediatric (DBP) programs available in the United States for APRNs, a program was started at Children's Specialized Hospital (CSH), Mountainside, New Jersey. Currently, this fellowship will support only one APRN per year. It is a 12‐month DBP fellowship and the fellow is considered a full‐time salaried employee of CSH (Children's Specialized Hospital, 2016). It is interesting to note that the KySS program is incorporated into the DBP curriculum.

There are other initiatives that regional organizations of the American Academy Child and Adolescent Psychiatry (AACAP) have undertaken in some parts of the country to support pediatric practices with varying models of continuing education and phone consultation for clinical support (American Academy of Child and Adolescent Psychiatry, 2010). One example is the Behavioral Health Integration in Pediatric Primary Care (BHIPP) program in Maryland. It is funded by the Maryland Department of Health and Mental Hygiene and operates as a collaboration between the University of Maryland School of Medicine, the Johns Hopkins Bloomberg School of Public Health, and Salisbury University (Behavioral Health Integration in Pediatric Primary Care, n.d.).

There was an initiative by the Association of Faculties of Pediatric Nurses Practitioners (AFPNP) to strengthen and evaluate the PNP mental health curriculum so that their classroom and clinical experiences prepared students to screen for, accurately identify, prevent, and provide early evidence‐based interventions for children and teens with mental, behavioral, and developmental problems in the primary care clinical setting (Melnyk et al., 2010). In 2004, the AFPNP, with financing from the Commonwealth Fund, built a model curriculum in mental health that was implemented in 20 PNP programs as part of a 3‐year study that looked at differences in outcomes for its graduates (Melnyk et al., 2010). The weakness identified then, and which still exists, is the scarcity of clinical sites where PNP students can put into practice (with preceptors) what they learn in the classroom (Hawkins‐Walsh et al., 2011; Melnyk et al., 2010). Faculty (66%) also identified that having an already “packed” curriculum was another barrier identified when implementing additional mental/behavioral health training to strengthen the PNP curriculum in this area (Hawkins‐Walsh et al., 2011).

Despite a job‐strong market and a slightly increasing number of PNPs being certified each year, a much greater percentage of NPs are ultimately choosing FNP programs due to the perception that this certification makes them more marketable (Freed et al., 2015). In 2016, more than 222,000 NPs are licensed in the United States (American Association of Nurse Practitioners, 2016). Of this group, 83.4% of NPs have a clinical focus in primary care; however, 55.1% are FNPs and only 6.4% are PNPs (American Association of Nurse Practitioners, 2016). Currently, no more than 2.4% of NPs are certified in Adult Psychiatric/Mental Health and 1.8% in Family Psychiatric‐Mental Health (American Association of Nurse Practitioners, 2016).

At the present time, the only way to obtain additional training in both didactic and clinical, except for on‐the‐job training, is by earning an additional postgraduate certification in a Psychiatric‐Mental Health program. There are at least 15 online postgraduate programs with clinical rotations close to students’ geographical location, where possible, to prepare primary care NPs to gain additional certification in psychiatric and mental health (Kverno & Kozeniewski, 2016). The Adult Psychiatric & Mental Health Nurse Practitioner has been retired because it did not meet the APRN Consensus Model requirements for role and/or population foci (American Nurses Credentialing Center, 2014). The Family Psychiatric Mental Health Nurse Practitioner certification changed its name to Psychiatric Mental Health Nurse Practitioner when the certification was updated. The descriptor that is used to describe the population, across the lifespan, is not included in the formal name of the certification. Family Psychiatric Mental Health NPs did not see a change to their existing credential; only the certification name changed. Those who earn a postmaster's certificate for the psychiatric mental health NP have the knowledge and competence to work in a variety of settings ranging from specialty behavioral health centers to primary care settings. Comorbid conditions may exist in children (Merikangas et al., 2015) and dually certified primary care NPs are better able to practice in a holistic fashion, addressing not only physical complaints but also more complicated mental health issues (Kverno & Kozeniewski, 2016).

All states currently allow PMHNPs to prescribe medications and provide clinical care to patients (American Psychiatric Nurses Association, 2015). PMHNPs work in a variety of settings, such as emergency rooms, hospital consultation and liaison services, outpatient settings, home‐based care settings, nursing homes, and psychiatric inpatient units (de Nesnera & Allen, 2016). Across the 50 states, there are many differing clinical and legislative mandates that NPs must adhere to, depending on the state where they practice (de Nesnera & Allen, 2016). There continue to be outdated regulations, biases, and policies that prevent all APRNs from practicing to the full extent of their education, skills, and competencies (Institute of Medicine, 2011).

NPs in primary care provide care that is comparable to physician care (Kaye et al., 2009; Martínez‐González et al., 2014). Even though NPs have been cited time and time again as providing quality care, being cost effective, safe, and sometimes preferred by patients (Fung, Chan, & Chien, 2014; Kaye et al., 2009; Martínez‐González et al., 2014; National Governors Association, 2012; Stanik‐Hutt et al., 2013), there still exists ambivalence about this rapidly expanding group of health professionals (Isaacs & Jellinek, 2012; Norton, 2013; Phoenix, Hurd, & Chapman, 2016; Stokowski, 2016). Even though many physicians highly value NP skills, some also believe that these skills have distinct limitations, and physicians are concerned that more reliance on these professionals might create a two‐tier system of caregivers with different competencies (Page, 2014). Therefore, this survey asked CAP and DBP program directors their thoughts about training NPs in their discipline.

Methods and materials

Design/setting

This descriptive study used a nine‐item national cross sectional survey to inquire about providing advanced training to NPs and the obstacles in doing so.

Sample

Survey Monkey was used to access 151 CAP and DBP training directors nationwide. The list of 116 CAP programs was obtained from the American Board of Child and Adolescent Psychiatry website. The list of the 35 DBP programs was obtained from the American Academy of Pediatrics website featuring developmental and behavioral pediatrics.

Instrument

An introductory letter was included with the survey (Table 1). The survey instrument was developed and further modified following the suggestions of several collegial CAP training directors who served as beta‐testing sites. All questions were open‐ended and the questionnaire is shown in Table 2. The final survey instrument contained nine questions, seven of them related to NP training in CAP and DBP.

 

Procedures

This study was approved by Solutions Institutional Review Board (IRB), Little Rock, Arkansas (Solutions IRB, 2014). A consent form was included for the participant to read prior to the survey and starting the survey implied consent. Survey Monkey was used to send the questionnaire and the majority (53%) responded online. As many as five additional requests were made through e‐mail, post, fax, and personal phone calls to capture as many of the nonresponders as possible. No incentive was initially offered to respondents, but when only 50% returned the survey, the rest were offered $10 (40% of respondents) and then $20 (10% of respondents) as inducement to complete and return the survey.

Statistical analysis

Univariate descriptive statistics were calculated to describe the sample characteristics. Categorical data were summarized by frequencies and percentages, while continuous data were summarized by the mean and standard deviation (SD). Excel (2016) and R (version 3.3) were used to conduct the statistical analyses. The upper and lower 20% quintiles were calculated (using fellows as a surrogate for the size of the programs) for each of the continuous variables.

To test whether there was a statistically significant difference in size of the two programs (CAP vs. DBP), the nonparametric Mann–Whitney U test was conducted because the data did not meet the assumptions of a two‐sample t‐test, namely, homogeneity of variance and normal distribution. To test the receptivity to program expansion based on the availability of funding, the Fisher's exact test was conducted in lieu of the chi square because the cell counts were not sufficiently large to meet the assumptions of that test.

Results

The return rate was 67% (101/151). Completed surveys were received from 78 CAP and 23 DBP training programs nationwide. The majority of responses to the survey (78%) were received via the Survey Monkey website. An additional 22% were received via telefax or by U.S. Postal Service. This was an open‐ended questionnaire so ambiguous responses, such as “maybe, possibly, possibly no, not sure, might consider, uncertain, open to consider, ambivalent, don't know, and not clear” were considered missing data and are identified as such in the tables. Results are reported in Table 3.

CAP training programs had a mean of 8 (SD 5.13) fellowship trainees per program and 12 (8.97) faculty. DBP training programs had a mean of 3 (SD 1.73) fellowship trainees and 6 (3.78) faculty. Based on the returned surveys, CAP programs were almost triple the number of DBP programs. Compared to DBP training sites, CAP training programs trained 70% more fellows.

Objection to the concept

Only 9% (8/65) of the CAP and 5% (1/20) of DBP training directors reported objections to the concept of providing advanced training for NPs.

Preexisting training

Programs that previously provided advanced training for APRNs was reported by 27% (21/78) of CAP and 44% (10/23) of the DBP respondents. Of the 21 CAP training sites who responded to this survey, 19% (15/78) were verified by personal communication to have trained one or more NPs, typically in an intensive and closely monitored on‐the‐job training for a few selected family and pediatric NPs and not in conjunction with a school of nursing.

Would expand, if funded

If sufficient funding were made available, 80% (48/60) of CAP training director respondents and 89% (17/19) of DBP training director respondents reported that they would consider expanding their training program to include NPs. Although as expected, the two programs were not equal in size using the Mann–Whitney U test (U = 1541.5; p < .001), the Fisher's exact test (p = 0.220) suggested no significant differences between the CAP and DBP directors in their support for establishment of advanced training in behavioral and mental health for NPs, if funding were available.

Definite plans to expand

Only 6% (4/75) of the respondents reported that they had firm plans to expand within the next 2 years. Respondents indicated that 5% (3/57) of CAP and 6% (1/18) of DBP programs had definite plans to expand.

Comments

In the comment section, 32% (32/101) responded (Table 4). The majority were very positive. Two respondents indicated they would prefer to educate physicians and another wanted to know who would have control over the NPs' training (child psychiatry versus schools of nursing). Another commented that salaries for NPs are only slightly lower than for developmental/behavioral physicians.

Discussion

This study surveyed the directors of both CAP and DBP programs nationwide about their receptivity and willingness to provide additional training for NPs who provide care to children with mental health issues and to examine the main obstacles to the development of such programs. One limitation of the study was the format of the survey and the open‐ended responses to questions which left room for ambiguous answers that resulted in some missing data. Even with missing data, the majority of the respondents reported that they supported training for NPs in mental health. Another limitation was not sending the survey to schools of nursing, who actually provide the graduate education. Lastly, there is no way to know if these findings generalize to the programs that did not respond to the survey.

Since one physician commented, “Who would have control over these training programs, child psychiatry or schools of nursing?” perhaps some are considering fellowships without input from nursing. But most nurses want to be certified in this nursing specialty, so this would have to be a conversation between the leaders of medicine and nursing, but it would seem unlikely nursing leaders would give control of their students’ education to medicine. Academic Practice Partnerships is the path advocated by nursing as a mechanism for advancing nursing practice to improve the health of the public (Beal et al., 2012). Nursing programs working together with CAP and DBP programs could educate NPs in a way that is both sustainable and cost effective. Dual certification for primary care NPs seems the most realistic path since adding to the already full academic curricula of primary care NPs could prove difficult. Another commented, “Salaries for NPs are only slightly lower than for developmental/behavioral physicians …,” which may imply that they saw no cost benefit in educating NPs.

Prospective students need to know that there is a real need for both PNP and PMHNP specialties, and encourage more to go into these fields. As has been previously suggested for increasing the number of nurses who opt for a PNP career, improved marketing about the benefits of a PMHNP career, both in the media and through word of mouth from nursing faculty and preceptors, could boost enrollment (Putre, 2015). Other incentives would be scholarships and loan forgiveness designated specifically for these graduate students (Putre, 2015).

PNPs who get advanced training through fellowships or have had an enhanced mental health curriculum in their graduate nursing program are also better prepared to provide mental health care in the primary care clinical setting. PMHNPs are trained to be prepared to provide the full range of psychiatric services, which includes the delivery of primary mental health care throughout the lifespan. But, even with certification in this specialty, are clinical preceptorships providing the type of training that meets the needs of children and parents in primary care? Training in psychotherapy, for example, cognitive and behavior therapies (CBT), that is effective for the more common mental health problems in children is needed. Since psychotherapy is more difficult to master than psychopharmacy, clinical sites need to provide a wide range of experiences to make this possible.

Mental health training for NPs should be a priority funding item and since so few opt for this specialty, incentives such as job placement should be offered. There is funding available for tuition reimbursement for NPs in designated shortage areas, which typically are rural communities, but even in nondesignated areas the effects of the shortage are seen. It can take many months to obtain an appointment with a child psychiatrist and usually it is an expensive out‐of‐pocket cost for parents because many psychiatrists will only accept cash due to poor reimbursement from insurance companies. The responses to the survey are encouraging considering the struggles there have been for NPs in primary care and the recent adversity that has played out in the press with the latest proposal by the Veterans Administration independent APRN proposal (Stokowski, 2016). As stated previously by nurses, “… the most profound action necessary for realizing the full potential of our profession lies in interorganizational unity and cooperation” (Apold & Pohl, 2014). As many have stated, our patients and their needs must come first.

Implications for practice

There is a serious chronic shortage of outpatient child and adolescent mental health professionals. The shortage is highly unlikely to improve without modifying and expanding the existing 116 CAP training programs and 35 DBP programs to include academic practice partnerships for training NPs. If federal or state funding can be secured and made available for programs, 82% (65/79) of all training directors who responded to this survey would be interested in expanding their current outpatient training program to include NPs. In‐depth, strikethrough outpatient pediatric mental health training for NPs should be a priority funding item and incentives such as job placement services are needed.


Acknowledgments

The authors gratefully acknowledge the help of the Inova Medical Library, Falls Church, Virginia, for help with obtaining reference material and the help of two additional NPs who have advocated for pediatric psychiatric mental health for many years and without whose assistance this article would not have been possible—Elizabeth Hawkins‐Walsh, PhD, CPNP, PMHS, FAANP, and Susan van Cleve, DNP, CPNP‐PC, PMHS, FAANP.


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