Perspectives on APRN prescribing of medications for opioid use disorder: Key barriers remain.

INTRODUCTION: Deaths from drug overdoses are rising dramatically in the United States. Treatment for opioid use disorders may include behavioral treatments as well as medications for opioid use disorders (MOUD). Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), other advanced practice registered nurses (APRNs), and physician assistants (PAs) and required a training and a federal waiver until recently. The number of NP MOUD prescribers grew steadily over the past decade, but research has identified state-level scope of practice regulations as a barrier to NP MOUD prescribing. This article explores the contributions of, and remaining barriers faced by NP and other APRN MOUD prescribers. We describe qualitative findings from a study of NPs and other key stakeholders involved in MOUD treatment in four states with two differing levels of regulatory structure. METHODS: In this qualitative study, we conducted site visits and semi-structured interviews with NPs and other APRNs, physicians, clinic managers, and regulators in four states including New Mexico and West Virginia (full practice authority for NPs), and Ohio and Michigan (which require physician supervision). Interview notes were entered into a qualitative software package and coded and reviewed by two members of the research team. Data were grouped into key themes. RESULTS: A total of 76 participants participated in individual or small group interviews in the four states. We found key themes and several subthemes that describe NP practice in MOUD. Participants described key contributions of NP engagement in MOUD, including increasing access, serving rural areas, the unique role of psychiatric NPs, and the value of the nursing model of care in working with people with substance use disorders (SUD). Participants also identified barriers including scope of practice regulations, other regulatory barriers, stigma, and lack of supportive services to address psychosocial needs. CONCLUSIONS: The waiver requirements were eliminated at the end of 2022 in federal budget legislation. Other barriers for NP and other APRN prescribers remain and should be addressed in practice, and in state and federal regulations. Research needs to explore the impact of the waiver elimination on MOUD prescribing and access to services.

Influences on advance practice nursing education to prescribe medications for opioid use disorder.

BACKGROUND: Opioid misuse is a major public health concern in the United States. Opioid agonist medications are evidence-based treatments for opioid use disorders (OUD) that can be prescribed by advance practice registered nurses (APRNs) with prescriptive authority and appropriate training. PURPOSE: Article examines factors influencing preparation to provide medications for opioid use disorder (MOUD) in APRN education. METHODS: Data from semi-structured interviews addressing the role of education in preparing APRNs to provide MOUD were grouped into key themes using thematic analysis. Data were collected in a mixed methods study in four states with high opioid overdose deaths whose main findings were previously published. FINDINGS: Two overarching themes emerged: "addressing attitudes" and "curriculum change." Sub-themes include affective barriers to providing OUD treatment; motivation to respond to the OUD crisis; and attitude change through experience with MOUD. DISCUSSION AND CONCLUSION: APRNs can play a key role in reducing the harms caused by OUD. Attention to attitudinal issues, such as stigma, toward people using opioids is important in educating APRNs about providing MOUD.

Psychiatric Nursing Workforce Survey: Results and Implications.

OBJECTIVE: The last national survey of psychiatric-mental health (PMH) nurses was conducted in 2016 and was limited to advanced practice registered nurses (APRNs). Data on the demographic and employment characteristics of the PMH workforce could inform how to optimize the PMH nursing workforce to address increasing demands for mental health services. The objective was to conduct a national survey of PMH registered nurses (RNs) and PMH-APRNs to gather data on their demographic, educational, and practice characteristics. METHODS: An email survey was administered between October 2020 and February 2021 to all members of the American Psychiatric Nurses Association and to all PMH-APRNs certified by the American Nurses Credentialing Center. Separate surveys included 51 questions (RN) and 52 questions (APRN). Survey questions were informed by several sources including the Minimum Data Set for the Behavioral Health Workforce. RESULTS: Surveys were completed by 4,088 PMH-RNs and 5,158 PMH-APRNs, with a combined response rate of 12.1%. Findings suggest that the workforce is aging but has increased slightly in diversity. In all, 62.4% of RNs reported a hospital as their primary employment setting, while the majority of APRNs (70.4%) practice in outpatient settings. Forty-four percent of the PMH-APRN respondents indicated that most of their patients receive federal insurance. CONCLUSIONS: Nursing must plan for significant retirements in the PMH workforce in next 5 years. Hospital-based practice continues to dominate PMH-RN roles but might be expanded to community-based settings teaming with PMH-APRNs in outpatient sites. Increasing the diversity of the workforce should be prioritized.

Buprenorphine Treatment: Advanced Practice Nurses Add Capacity.

During the COVID-19 pandemic, there was slower growth in the number of new waivers authorizing clinicians to provide buprenorphine treatment for opioid use disorder. However, treatment capacity grew at a stable rate as a result of already authorized clinicians obtaining waivers for larger patient panels. Advanced practice nurses accounted for the largest portion of capacity growth during the pandemic.

Effect of state regulatory environments on advanced psychiatric nursing practice.

The first key message in the landmark Future of Nursing report is that "Nurses should practice to the full extent of their education and training" (Institute of Medicine, 2011). Although there has been significant progress across states to remove or diminish barriers to the exercise of full scope of practice by advanced practice registered nurses (APRN), state regulations continue to unnecessarily restrict APRN practice in most of the United States. This article integrates data from studies that examine how state and local regulation affects psychiatric mental health APRN practice with the literature on how state scope of practice regulation affects the size and distribution of the broader APRN workforce, access to care, health care costs and prices, and innovation in health care service delivery. Common themes include confusion about regulatory requirements and mixed experiences of mandated physician supervision.

How collaborative practice agreements impede the provision of vital behavioral health services.

BACKGROUND: The critical shortage of behavioral health professionals impairs the ability of the U.S. health care system to respond to the growing demand for services to address mental illness and substance use disorders. PURPOSE: To identify how restrictive state regulations act as barriers to full utilization of psychiatric mental health advanced practice registered nurses (PMH-APRN), whose scope of practice enables them to provide a full range of behavioral health services. METHODS: A sequential mixed methods study combining interview data (n = 94) from a qualitative study of PMH-APRN practice with a subset of quantitative data (n = 699) from a national APRN survey examining the impact of state-mandated APRN/MD collaborative practice agreements. DISCUSSION: Data sources converged to portray challenges to optimal use of APRNs providing psychiatric/mental health services, including high out-of-pocket fees, irregular communication with supervisors, mandated chart reviews, and supervisor turnover. CONCLUSION: Inconsistent and burdensome supervision requirements contribute to cost inflation and may limit patient access.

The Current Psychiatric Mental Health Registered Nurse Workforce.

OBJECTIVE: To define and describe the current psychiatric mental health registered nursing (PMHN) workforce providing care for persons with mental health and substance use conditions, evaluate sources of data relevant to this workforce, identify additional data needs, and discuss areas for action and further investigation. METHOD: This article uses currently available data, much of it unpublished, to describe the current PMHN workforce. RESULTS: The available data indicate that PMHNs represent the second largest group of behavioral health professionals in the United States. As is true of the overall nursing workforce, PMHNs are aging, overwhelming female, and largely Caucasian, although the PMHN workforce is becoming more diverse as younger nurses enter the field. PMHNs are largely employed in the mental health specialty sector, and specifically in institutional settings. Similar to other behavioral health professionals, a significant shortage of PMHNs exists in rural areas. Because of data limitations and difficulty accessing the best available data on the PMHN workforce, it is often overlooked or mischaracterized in published research and government reports on the behavioral health workforce. CONCLUSIONS: Although PMHNs are one of the largest groups in the behavioral health workforce, they are largely invisible in the psychiatric literature. Psychiatric nursing must correct misperceptions about the significance of the PMHN workforce and increase awareness of its importance among government agencies, large health care organizations, and within the broader nursing profession.

Utilization and Economic Contribution of Psychiatric Mental Health Nurse Practitioners in Public Behavioral Health Services.

INTRODUCTION: Expanded insurance coverage through the Affordable Care Act and parity in behavioral health coverage have increased demand for services. Yet there is a persistent shortage in the behavioral health workforce. Psychiatric Mental Health Nurse Practitioners (PMHNPs) may be part of the solution to shortages but are not yet fully utilized. The purpose of this study was to describe how PMHNPs are utilized, identify barriers to full utilization, and assess PMHNPs' economic contribution in public behavioral health systems. METHODS: This study used a mixed methods approach, selecting counties for use of PMHNPs, geography, population size, rural/urban, and availability of financial data. The authors conducted 1- to 2-day site visits in 2014-2015 including semi-structured interviews with management and clinical leaders and collected PMHNP staffing and billing data. Thematic analysis of interview data was conducted and aggregate staffing and billing data were analyzed to determine net PMHNP financial contribution. RESULTS: The primary billed service for PMHNPs is medication management. Barriers to full utilization included system-level barriers to hiring PMHNPs, lack of role-appropriate job descriptions, confusion related to scope of practice/supervision requirements, and challenges in recruitment and retention. Fiscal analysis showed a positive net contribution from PMHNP services. CONCLUSIONS: PMHNPs can make a significant contribution to behavioral healthcare delivery, particularly in public mental health settings, yet greater understanding of their role and addressing barriers to practice is needed. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Experience of Psychiatric Mental Health Nurse Practitioners in Public Mental Health.

Expansion of health insurance coverage under the Accountable Care Act has meant that millions of people are now insured for mental health treatment, but with no significant increase in the mental health workforce. Services of psychiatric mental health nurse practitioners (PMHNPs) may be best utilized to improve access to and quality of public mental health services if the financial, political, scope of practice, and treatment model barriers that limit their ability or willingness to practice in these settings are better understood. This article reports qualitative results from a study that assessed barriers and best practices in the use of PMHNPs in county mental health services in California. Results indicate that PMHNPs are valued for their "whole person" perspective, collaborative approach, and interpersonal communication skills, but that significant knowledge gaps, regulatory constraints, and bureaucratic barriers in public mental health systems inhibit PMHNPs from practicing at the top of their scope.

Co-occurrence of anxiety and depressive symptoms following breast cancer surgery and its impact on quality of life.

PURPOSE: Little is known about the prevalence of combined anxiety and depressive symptoms (CADS) in breast cancer patients. Purpose was to evaluate for differences in demographic and clinical characteristics and quality of life (QOL) prior to breast cancer surgery among women classified into one of four distinct anxiety and/or depressive symptom groups. METHODS: A total of 335 patients completed measures of anxiety and depressive symptoms and QOL prior to and for 6 months following breast cancer surgery. Growth Mixture Modelling (GMM) was used to identify subgroups of women with distinct trajectories of anxiety and depressive symptoms. These results were used to create four distinct anxiety and/or depressive symptom groups. Differences in demographic, clinical, and symptom characteristics, among these groups were evaluated using analyses of variance and Chi square analyses. RESULTS: A total of 44.5% of patients were categorized with CADS. Women with CADS were younger, non-white, had lower performance status, received neoadjuvant or adjuvant chemotherapy, had greater difficulty dealing with their disease and treatment, and reported less support from others to meet their needs. These women had lower physical, psychological, social well-being, and total QOL scores. Higher levels of anxiety with or without subsyndromal depressive symptoms were associated with increased fears of recurrence, hopelessness, uncertainty, loss of control, and a decrease in life satisfaction. CONCLUSIONS: Findings suggest that CADS occurs in a high percentage of women following breast cancer surgery and results in a poorer QOL. Assessments of anxiety and depressive symptoms are warranted prior to surgery for breast cancer.

Promoting resilience and recovery in a Buddhist mental health support group.

Communities of faith are important arenas for psychiatric mental health nurses to promote emotional well-being and support recovery for persons with mental health problems. This article describes an innovative faith-based mental health group, based on Buddhist philosophy and practice and established by an advanced practice psychiatric nurse, that uses psychoeducation, peer support, and faith encouragement to help participants find hope and meaning in the experience of mental health problems. A brief overview of Buddhism and selected concepts relevant to the philosophical framework of the Buddhist mental health support group is followed by a review of the common themes of the group discussions. These include: finding value in the illness experience; differentiating the proper role of treatment from that of Buddhist practice in optimizing mental health; and experiencing a deeper sense of joy, despite current suffering.

Psychoeducation for survivors of trauma.

PURPOSE: Education about the persistent effects of trauma helps survivors better understand their own stress responses, and knowledge of coping strategies provides a sense of control over these responses. Trauma education for providers can minimize negative countertransference and prevent vicarious traumatization. CONCLUSIONS: This article discusses content areas to be covered in psychoeducation with survivors of acute traumatic events and prolonged trauma and abuse, and reviews resources for trauma psychoeducation with clients and healthcare providers. PRACTICE IMPLICATIONS: Advanced practice psychiatric nurses may provide psychoeducation to people who suffer from complex psychological and behavioral disturbances related to severe and persistent abuse or trauma, especially early in life.