The Evolution of the Psychiatric Nurse Practitioner

The field of mental health presents a number of professionals to provide care for individuals. One member of that team is the psychiatric mental health nurse practitioner (PMHNP). In 1946, the United States passed the National Mental Health Act, which established psychiatric nursing as one of the four core mental health disciplines. The Act included funding for the development of advanced educational programs for mental health nursing.

The PMHNP was born from the need for mental health support staff in the 1950s. Dr. Hildegard Peplau developed a graduate program at Rutgers University for a psychiatric mental health clinical nurse specialist (CNS). The emphasis at that time was on providing psychotherapy, but the skill set grew to organizational analysis and consultation services. The Community Mental Health Centers Act of 1963 helped expand the scope of CNS practice. Over time, the CNS assumed roles at hospitals, community centers, and private practice. The establishment of Medicare and Medicaid in 1965 further expanded mental health nursing practice.

The role of the CNS has changed over time as educational preparation for PMHNPs not only addressed psychotherapy, but also included pathophysiology, health assessment, and pharmacology. A national panel developed these additional competencies for PMHNPs due to the decline in the number of nurses choosing to pursue the CNS role. The PMHNP is now able to provide direct mental health services to consumers, including assessment, diagnosis, and treatment planning. The use of pharmacological and non-pharmacological approaches was also included. The CNS role continued to see a decline in the 2000s after the core competencies for graduate education of all advanced practice nurses moved in the same educational direction.

The PMHNP role grew in the early 1990s as research showed the need for primary mental health services and mental illness prevention. Since both physical and mental health issues needed to be considered, the PMHNP appeared to be a good fit. The American Nurses Credentialing Center provided a certification exam in 2001, which further solidified the PMHNP’s role in the mental health service arena. The initial role of PMHNPs at the hospital expanded into the community, and by 2007, 68 percent of PMHNPs were providing community care. The majority of states in the U.S. allowed prescriptive authority as part of the scope of practice, allowing the PMHNP to prescribe medications autonomously.

The PMHNP now had a combination of skills that allowed them to work in multiple settings over time. The advent of health care reform and the Affordable Care Act focused attention on practices that promoted holism, prevention of mental illness, and mental wellness. This new emphasis on many of the health models proposed combined primary health care and behavioral health care services in one location in the community. Given that the educational preparation includes psychotherapy, pharmacology, physical assessment, and pathophysiology the PMHNP role fits the identified need.

The psychiatric mental health nurse organizations supported the PMHNP role in response to the consensus model for advanced practice registered nurses (APRNs) and state regulations. This document was constructed with the collaboration of nursing educational institutions, accrediting bodies, certification institutions, and licensing bodies across the United States. Psychiatric mental health nursing leaders developed recommendations for the implementation of the model for advanced practice nurses and psychiatric mental health. The recommendation put forth by the committee was one entry educational focus for the future with preparation across the lifespan, addressing mental health promotion and mental illness diagnosis and treatment. Further, psychotherapeutic modalities were identified as essential in educational programs.

The role of the PMHNP has expanded as societal needs in the mental health arena have increased. This developing workforce continues to require a strong educational basis and continued focus on expanding evidence-based practice. Continued political activism is necessary to remove regulatory barriers at the state level that affect the full scope of practice of the psychiatric mental health nurse practitioner.