Filling the Mental Health Provider Void

Many Americans who need mental health treatments are going without for a lack of trained providers. During the first year of the COVID-19 pandemic, 32 percent of American adults who thought they might need such services or treatment did not get them, according to an April 2021 Kaiser Family Foundation (KFF) survey. The primary reason—ahead of even cost and time—was accessibility: 24 percent of respondents said they could not find a mental health provider.

As a result, some adults and children suffering from depression, bipolar disorder, and other mental health conditions are waiting weeks to months to see a mental health provider, while others can’t find nearby providers who are accepting new patients. COVID-19 has drawn more attention to this mental health workforce shortage as increasing numbers of people report symptoms of depression and anxiety disorders (41 percent in January 2021, compared to 11 percent in 2019, according to another KFF report).

The School of Nursing and Health Studies (SONHS) is addressing this provider shortfall through its Post-Master’s Certificate in Psychiatric Mental Health Nursing, a program for nurse practitioners (NPs) interested in pursuing careers as psychiatric mental health nurse practitioners (PMHNPs). “We need more nurse practitioners who can care for the mentally ill,” says the program’s director Deborah “Debbie” Salani, B.S.N. ’86, M.S.N. ’89, D.N.P. ’12, PMHNP-BC, APRN, an associate professor of clinical. “Our hope is that our students will go into practice and advocate for those vulnerable individuals who don’t have a voice.”

The United States is short 6,464 psychiatrists, according to data from the U.S. Health Resources and Services Administration, which has set a goal of one psychiatrist for every 30,000 people (or one for every 20,000 in high-need communities). “PMHNPs are well-positioned to play a vital role in bridging these care and service disparity gaps,” explains board-certified PMHNP Horace Ellis, B.S.N. ’95. Ellis is a doctorally prepared nurse practitioner and clinical specialist at Miami’s Jackson Behavioral Health Hospital, one of eleven established preceptor sites for students in the SONHS post-master’s certificate program. Jackson Behavioral Health has tripled the number of PMHNPs on staff from two to six in recent years, says Ellis. “There’s always a need for more PMHNPs.” The psychiatric mental health certificate program at SONHS is growing rapidly, helping to fill workforce needs. In 2019, Salani’s first year as director, the program graduated 11 students; in 2020, there were 18 graduates. The 2021 class has 32 members enrolled.

Once they pass board exams, PMHNPs are licensed to assess, diagnose, and treat mental health disorders. As NPs, they can prescribe medications. State laws vary on whether and how long NPs must practice under the super vision of a physician. In Florida, PMHNPs can practice autonomously if they’ve been an NP for five years and complete the necessary requirements.

Graduates of the SONHS program help patients in a variety of settings, from inpatient psychiatric hospitals to community health networks and substance use disorder programs. In addition, the COVID-19-era boom in psychiatric telehealth services is offering PMHNPs new opportunities to work from home.

Dawn Smith Walsh, who received the student PMHNP award of her 2020 cohort, is fulfilling a lifelong passion to work in mental health. She currently works at a geriatric practice in Tampa with her former SONHS clinical preceptor. “It brings tears to my eyes when I have an ‘aha’ moment with a patient and [he or she] realizes I’m there to help and not judge,” says Smith Walsh, a PMHNP and adult-gerontology nurse practitioner.

A Year in the Life

The SONHS program runs from January to December, packing those 12 months with in-depth classroom learning and intensive patient interactions. “My main goal for the program is to educate our students to be amazing clinicians who are comfortable practicing independently,” Salani says.

The 2020 class’s performance on the PMHNP board certification exam suggests Salani is attaining her goal.

“Our programmatic strategies find high success with our national board certification pass rate of the 2020 cohort at 100 percent, while the national average is 80 percent,” she points out.

Each spring, first-semester students learn about the various mental health disorders and criteria used to diagnose each. “We cover most of the DSM-5 textbook, which is like the Bible of psychiatry,” explains Salani, referring to the Diagnostic and Statistical Manual of Mental Disorders. “Additionally, the students learn psychopharmacology and other treatment strategies, including therapy, for mental disorders.”

Thanks to SONHS’ Simulation Hospital Advancing Research and Education (S.H.A.R.E.TM), instructors have incorporated psychiatric simulations into the PMHNP program as well. For instance, one semester, students had to identify how to diagnose and treat a patient presenting at emergency department with heart palpitations, shortness of breath, nausea, and other symptoms of a panic attack.

PMHNP students also are required to complete 504 clinical hours. In Larkin Community Hospital’s South Miami Campus, the PMHNP students rotate through inpatient and outpatient settings, seeing patients in the adult crisis stabilization unit, adolescent inpatient unit, emergency department, and outpatient clinics. They also participate in outpatient therapy sessions.

Preceptor Rene Miguel Hasbun is Larkin’s program director for outpatient behavioral health. “The students shadow our residents and the attendings,” says Hasbun, a nationally certified, licensed mental health counselor and master’s level-certified addiction professional.

“When patient’s exhibit psychiatric needs, our staff provides a comprehensive evaluation. The psychiatric resident and PMHNP preceptees evaluate the patient together and present the case to the attending, who works with them, asking questions like, ‘What do you think the treatment should be?’”

Experiential learning is key to becoming a successful practitioner, notes Ellis. At Jackson Behavioral Health, students conduct psychiatric evaluations, formulate diagnoses and treatment plans, write prescriptions, and assess for medication side effects. “Preceptees learn a great deal during clinical rotations because they are able to transfer what they have learned in theory into practice,” says Ellis.

One of the biggest lessons Janella San Juan, B.S.N. ’14, a 2020 graduate of the PMHNP certificate program, learned during her clinical rotation at Advent Health Orlando was the importance of listening. “I remember my preceptor told me the best thing to do is to be still and listen to the patient,” she recounts. “It’s such simple advice, but it can be powerful. We have to always be respectful of patients and give them time to talk.”

The UM Draw

SONHS was San Juan’s first and only choice for her PMHNP studies. She had completed her undergraduate nursing degree at the University of Miami and valued the education she received. “I knew the nursing education was top- notch and the professors were great,” she offers. “It was the only program I applied to.”

San Juan’s classmate Smith Walsh, a Tampa resident, took a more data-driven route to selecting SONHS, creating a spreadsheet to help her pinpoint the pros and cons of eight post-master’s psychiatric mental health certificate programs around the United States. “I chose UM because the program is succinct yet comprehensive, which is difficult to find,” Smith Walsh says, noting that other programs she investigated ranged from 18 months to two years. The hybrid learning structure SONHS offers—with 50 percent of coursework online and the rest conducted in person—was another deciding factor.

“UM prepared me quite well!” she says. “A lot of students have told me that they’re thrilled to be a part of UM because it is a very prestigious university,” offers Salani, “but the other big selling point is our hybrid approach. They like that the program is not all online. They like to come to campus and network with their classmates.”

Another advantage to the SONHS program, which is accredited through 2031 by the Commission on Collegiate Nursing Education, is the range of clinical preceptorships available. Some post-master’s certificate programs expect students to schedule their own clinical hours, but Salani has worked hard to line up preceptorships that place all students directly at a variety of clinical sites. This helps ensure that each PMHNP student gains experience in the mental health specialty they are most interested in.

This collaborative approach also benefits the School’s clinical partners by helping them train PMHNPs to work with their patient populations and in their care sites, suggests psychiatrist

Maria Collado, M.D., clinical director of the adult crisis stabilization unit at Hialeah-based Citrus Health Network, another key placement site for PMHNP students from SONHS.

“There is a growing need for well-trained psychiatric-mental health practitioners who understand and have experience with treating patients within a community-based model,” says Collado, an assistant professor of clinical medicine for FIU Herbert Wertheim College of Medicine at Citrus Health Network. “We are proud to offer training slots for these professionals and hope to build a career pathway for them.”

Making an Impact

Because of their nursing background, PMHNPs bring a needed focus on the whole patient to psychiatric consultations and treatment. “I like to say that nurse practitioners wear a lot of hats,” says San Juan, who has been hired as a PMHNP for a telepsychiatry company in California. “We’re not just providing medications. We also educate and sometimes do a little bit of case management. That goes hand in hand with the holistic approach to patient care that has been instilled in us in nursing school.”

Smith Walsh shares a story from her preceptorship at a private practice that illustrates the important work of PMHNPs. One of her patients went into a deep depression after having her leg amputated. The woman, who had to stay in the hospital for a long time after the operation, missed her husband terribly and cried continuously. Then a close relative died and the woman was unable to attend the memorial service in person because of her condition. This caused the patient to become severely anxious in addition to being depressed.

To help, Smith Walsh and her clinical partner prescribed a short course of benzodiazepine as well as an antidepressant. Within weeks, the patient had made a remarkable turnaround. “She was in her wheelchair wheeling around the unit and interacting with people,” recalls Smith Walsh. The patient had been able to attend the memorial service via Skype and shared screenshots from the event with her.

“It’s so wonderful when you can help a patient change their perspective and change their story,” Smith Walsh says. Program director Salani, a graduate of the program herself, hopes more nurses who are passionate about caring for those with mental disorders will consider becoming PMHNPs. Her message to them: “You are needed.”

This story originally appeared in the Fall 2021 issue of Heartbeat magazine