Nurses care for mental health
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Nursescareformentalhealth2.pdf
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Developing a well-prepared and geographically distributed mental health workforce is a crucial goal of healthcare workforce planning initiatives and contributes to health systems’ ability to improve population health (Beck et al., 2020). Before the SARS COV-2 global pandemic, sharp increases in suicide, substance abuse, opioid crises, gun violence, and severe depression among young people were increasing demands on mental and behavioral health professionals, including nurses (Substance Abuse and Mental Health Services Administration, 2020). However, the growing demand for behavioral health services, let alone treating the 44 million American adults who have a diagnosable mental health condition, is being met by a potential shortage of professionals, which the Health Resources and Services Administration (2016) projects will worsen to as many as 250,000 workers by 2025. Access to mental health care is
crucial given the societal upheaval brought about by the SARS COV-2 global pandemic.
To address the growing demand for mental health services, many communities and healthcare systems are exploring novel ways to integrate mental health treatment into primary care delivery, for example, using the Collaborative Care Model (Vanderlip et al., 2016). Nurses often contact people living with mental or behavioral health conditions while being treated for physical and medical conditions in both community and hospital settings. A recent focus on mental health care, particularly in outpatient settings, has been an emphasis in team-based models, telehealth, and integration of mental health and primary care with contributions from physicians, nurses, social workers, peer support, and community health workers – all of which can be beneficial relative to more traditional and often siloed models of mental health treatment (Reiss-Brennan et al., 2016).
Characteristics of Registered Nurses and Nurse Practitioners Providing Outpatient Mental Health Care David I. Auerbach Max C. Yates
Douglas O. Staiger Peter I. Buerhaus
The growing demand for mental health services, together with current and increasing shortages of mental health professionals and increasing adoption of integrated models of care delivery, suggest nurses will become increasingly needed to provide mental health services. Analysis of a national survey finds registered nurses and nurse practitioners working in outpatient mental health settings are older than those in other settings. Most would benefit from additional training. Provision of team-based care was associated with higher job satisfaction.
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The growing demand for mental health services, together with current and increasing shortages of mental health professionals and increasing adoption of integrated models of care delivery, suggest nurses will become increasingly needed in providing mental health services. Registered nurses (RNs) who provide mental health services help establish a patient’s diagnosis, develop a plan of care, coordinate services, and evaluate treatment effectiveness, among other activities. Nurse practitioners (NPs) who provide psychiatric and mental health care often lead care delivery teams, prescribe medications (Alexander & Schnell, 2020), including buprenorphine (Barnett et al., 2019; Spetz et al., 2019), provide psychotherapy, and coordinate care with other providers.
Prior research based on the National Sample Survey of Registered Nurses (NSSRN), arguably the most comprehen - sive, detailed representative survey of RNs available, found the mental health nursing workforce is relatively older, female, and White compared to other nurses (Hanrahan & Gerolamo, 2004; Hanrahan 2009). However, data used in these studies came from the 2000 and 2004 waves of the NSSRN when integration models, use of telehealth, and other contemporary mental healthcare features were not in use and, therefore, not assessed in these surveys. In this data brief, the recently released 2018 NSSRN is used to update and
describe key demographic attributes of RNs and NPs providing outpatient mental health services and characteristics of their practice.
Data and Methods
Data for the study come from the 2018 NSSRN, a comprehensive survey of RNs developed and administered by the U.S. Health Resources and Services Administration with assistance from the U.S. Census Bureau. The survey assessed the number of RNs in the United States and contains questions regarding RNs’ educational background, employment setting, job position, salary, geographic distribution, social and demographic characteristics, job satisfaction, and other information. The NSSRN has been fielded every 4 years from 1977 to 2008 and again in 2018 when most questions related to surveyed RNs’ status as of December 31, 2017. The 2018 NSSRN heavily oversampled NPs, with surveys mailed to approximately 50,000 (roughly 1 in 4) NPs, and obtained a 50% response rate. This data brief focuses on RNs and NPs working in outpatient mental healthcare settings and, in some cases, compares their characteristics with the overall RN and NP workforce.
A descriptive analysis was conducted of key survey questions pertaining to individual and practice characteristics. Frequencies, means, and RNs’ and NPs’ perceptions of their use of teamwork and telehealth, job
satisfaction, and educational content that would help them do their jobs better were reported. The samples of mental health RNs and NPs were weighted using weights provided by the NSSRN. All analyses were performed using Stata version 16.
Results
As shown in Table 1, 100 RN and 734 NP respondents to the survey working in outpatient mental health settings were identified. These nurses represent just under 15,000 RNs (0.6% of the RN workforce) and 5,776 NPs (2.7% of the NP workforce). RNs working in outpatient mental health are considerably older than other RNs, with just under 10% under age 35 compared to 22% of all other RNs, and nearly half are 50 and over. These RNs are more likely to be non-White and have lower earnings than other RNs, despite being older. NPs working in outpatient mental health settings are also older than other NPs, with more than half over 50 compared to 37.5% of all other NPs. A similar fraction is non-White, more are male, and earnings are slightly higher than other NPs.
Team-Based Care The extent to which
outpatient mental health RNs and NPs practice team-based care, which is a critical aspect of many prominent and innovative mental healthcare models, was explored.
The majority of RN and NP respondents indicated they
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Table 1. Number and Characteristics of Mental Health RNs and NPs in the United States, 2018
Outpatient Mental Health RNs (n=100)
All other RNs (n=22,962)
Outpatient Mental Health NPs
(n=734) All other NPs
(n=20,781)
Number (weighted) 14,995 2,708,393 5,776 204,230 Age Group
Under 35 9.9% 22.4% 12.1% 17.2% 35-49 42.6% 36.8% 36.9% 45.3% 50+ 47.5% 40.8% 51.0% 37.5%
Non-White 39.1% 28.3% 26.1% 25.3% White 60.9% 71.7% 73.9% 74.7%
Female 88.7% 89.4% 86.1% 89.8% Male 11.3% 10.6% 13.9% 10.2%
Annual Earnings $67,292 $75,077 $111,685 $106,435
Figure 1. Extent to Which RNs and NPs Practice Team-Based Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0 Outpatient mental
health RNs All other RNs Outpatient mental
health NPs All other NPs
A great extent Somewhat Very little Not at all N/A
8%
17%
69%
6%
21%
64%
11%
29%
57%
9%
27%
59%
5% 5%0 3% 1% 3%
2% 3%
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practice team-based care (see Figure 1). A solid majority (69%) of outpatient mental health RNs practiced team-based care to a great extent, slightly higher than the percentage for all other RNs (64%) and higher than the rate of outpatient mental health NPs (57%).
There are many forms of team-based care training. Different types of team-based care training RNs and NPs reported receiving are shown in Figure 2. More than half of all RNs and NPs received informal on-the-job training in team- based care, and fewer than 1 in 5 have not received any training. RNs were more likely to have received formal on-the- job training and educational videos, while NPs were more
likely to have received training during their educational program. RNs and NPs working in outpatient mental health settings were no more likely to receive team-based care training, despite the fact both types of nurses in these settings were more likely to practice team-based care than other RNs.
The association between team-based care in the workplace and RNs’ and NPs’ job satisfaction ratings was examined. Although questions are asked independently of each other in different sections of the questionnaire (e.g., satisfaction is not explicitly linked to team- based care), and many factors influence satisfaction, an observed relationship could provide suggestive evidence that
outpatient mental health RNs and NPs find a team-based environment more satisfying. The combined responses of RNs and NPs are shown in Figure 3 and reveal nurses practicing team-based care either somewhat or to a great extent are overwhelmingly satisfied with their jobs. More than 90% of those practicing team-based care to a great extent agreed they are extremely or moderately satisfied; 85% of those practicing team-based care somewhat reported high levels of satisfaction. On the other hand, among RNs and NPs who practice team-based care very little, more were dissatisfied than satisfied. This difference persisted, although the magnitude diminished
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Figure 2. Type of Training in Team-Based Care Received
70%
60%
50%
40%
30%
20%
10%
0 Formal:
School-based Formal:
On the job Educational
videos at place of employment
Informal on the job
None
Outpatient mental health RNs All other RNs Outpatient mental health NPs All other NPs
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somewhat relative to that observed in Figure 3, when controlling for RN or NP age, earnings, gender, and race/ethnicity in a multivariate regression analysis.
Telehealth Use of telehealth in the
workplace among outpatient mental health RNs and NPs was also examined (see Figure 4). Overall, nearly half of outpatient mental health RNs (43%) and NPs (47%) reported telehealth was used in their workplaces in 2018, substantially higher than RNs and NPs working in other settings.
These differences mirror reports of higher telehealth use in providing mental health services during the pandemic (IQVIA, 2020). When RNs and
NPs were asked about their telehealth with patients (as opposed to whether it was used in their workplace), only 1 in 5 outpatient mental health RNs and 1 in 4 outpatient mental health NPs had used telehealth, with use evenly divided among direct interactions with patients and provider-to-provider consults.
Finally, the 2018 NSSRN asked all RNs and NPs, “What training topics would have helped you do your job better?” Those working in outpatient mental health responded that mental health training would have helped (see Figure 5). Even among those not working in outpatient mental health, 31% of NPs and 23% of RNs responded they would have fared better in their job if they
had received training in mental health. In addition to outpatient nurses, 51% of RNs working as school nurses, 44% of RNs in emergency settings, and 37% of RNs in public health also agreed mental health training would have helped them do their jobs better.
Discussion
In the context of growing demand for mental health care, shortages of mental health professionals, and innovations in mental health service provision, this study used recently released survey data from the 2018 NSSRN to assess critical characteristics of nurses providing outpatient mental health care in the United States. RNs’ and NPs’ involvement in
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Figure 3. Job Satisfaction of Outpatient Mental Health RNs and NPs (Combined) Based on Extent to Which They are
Currently Practicing Team-Based Care
60%
50%
40%
30%
20%
10%
0 A great extent Somewhat Very little
Extremely satisfied
Moderately dissatisfied
Moderately satisfied
Extremely dissatisfied
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Figure 4. Telehealth Use Among Outpatient Mental Health RNs and NPs and Among All other RNs and NPs
50% 45% 40% 35% 30% 25% 20% 15% 10% 5%
0 Telehealth use in
workplace? Personal use in
telehealth? Provider-to-patient
direct calls or e-visits Provider-to-provider
direct consults
Outpatient mental health RNs All other RNs Outpatient mental health NPs All other NPs
Figure 5. Percentage of RNs and NPs Who Agreed that More Training in Mental Health During their Educational
Program Would Have Helped Them Do Their Current Job Better
80%
70%
60%
50%
40%
30%
20%
10%
0 Outpatient mental
health RNs All other RNs Outpatient mental
health NPs All other NPs
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team-based care, telehealth, and other aspects of outpatient mental and behavioral healthcare delivery were assessed and can help illuminate the adequacy and preparation of the mental health nursing workforce. Results can assist health policy and workforce planners build the mental health workforce needed by society, particularly in light of the impacts of the continuing SARS COV-2 global pandemic.
As in the case of earlier studies (Hanrahan & Gerolamo, 2004; Hanrahan 2009), evidence indicates RNs and NPs working in outpatient mental health settings are significantly older than other RNs and NPs, which suggests many mental health nurses are likely to retire before the end of the decade. Unless they are replaced by younger RNs prepared in mental health, shortages of nurses in mental health outpatient settings could develop and possibly decrease access to mental health care. Hunter and colleagues (2015) found nursing students felt unprepared to pursue careers in mental health care, though additional, positive clinical experiences could help overcome this barrier. Delaney and Vanderhoef (2019) noted a promising, wide variety of potential clinical training sites, including hospitals, ambulatory sites, schools, prisons, and Veterans Administration facilities.
Because earnings of RNs in outpatient mental health settings are substantially lower than other RNs, employers should consider their wage policies as a tool to promote RNs’ interest in
mental health. Although most RNs working in mental healthcare settings are female, they are slightly more racially diverse than RNs working in other locations. While the latter finding contrasts with studies in the early 2000s referenced earlier, they are consistent with more recent work that found increasing diversity among recent entrants to the psychiatric nursing workforce (Phoenix, 2019).
Concerning NPs, results from the current study show NPs working in outpatient mental health settings are similar to RNs in that they are considerably older than NPs working in different settings. Unlike the lower earnings of RNs relative to others, NPs working in mental health settings earn more than most NPs working in other settings. About 75% of outpatient mental health NPs (and NPs generally) are White, suggesting efforts to attract under-represented minorities into psychiatric and mental health NP education programs are needed.
Team-based care and telehealth are integral to new and emerging models of mental health care. Study results reveal 70% of RNs and 57% of NPs working in outpatient mental health settings report team- based care is used to a great extent in their workplaces. Because more RNs reported receiving training in team-based care in the workplace than NPs, this could explain some of the differences in team-based care between RNs and NPs. Importantly, team-based care
appears linked to higher levels of job satisfaction among outpatient mental health RNs and NPs.
Higher proportions of RNs and NPs working in outpatient mental health care settings reported telehealth use relative to RNs and NPs in other locations. This difference could be due to telehealth’s high efficacy for providing mental health services (Totten et al., 2019). Greater use of telehealth has been noted in numerous reports during the COVID-19 pandemic, with telehealth being primarily responsible for maintaining care levels for mental health conditions close to pre-pandemic levels, unlike most other conditions (IQVIA, 2020). Still, telehealth use among RNs and NPs in mental health settings was relatively low in 2018; around 10% of both types of nurses had used telehealth for direct patient calls or provider-to-provider consults. RNs’ and NPs’ use of telehealth with patients has grown during the pandemic. Some of this growth is likely to persist once nurses and other providers and patients gain experience with the medium.
Finally, most RNs and NPs in outpatient mental health settings indicated they could have done their jobs better had they received more training in mental health. This result could reflect expanded caseloads, increasingly complex patients, or that mental health training was inadequate and could be improved. Even among those not working in outpatient mental health, the large number of RNs and NPs
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who responded they could have done their jobs better if they had received more training in mental health suggests training be made a priority in nursing education curricula, student clinical experiences, professional continuing education offerings, and in-service education programs.
Summary
The 2018 NSSRN provides rich information about crucial aspects of RNs and NPs employed in outpatient mental health treatment settings. This information enables development of a critical baseline on these nurses’ experience, competency, and training around team-based care, telehealth, and training in mental health care. Data indicate many RNs and NPs working in these critical aspects of care have the building blocks to participate in advanced models of mental and behavioral health care and integration with primary care. Still, additional training and experience with mental health care are critical to future workforce adequacy.
Future NSSRNs should continue to include these topics as well as questions regarding nurses’ opinions of the efficacy of telehealth, barriers to adoption, and optimal use. Similarly, RNs and NPs could be asked about the obstacles to developing and sustaining effective team-based care, the benefits of team-based care to patients, healthcare professionals and organizations, and their
views about who (physicians, nurses, NPs, social workers, or others), in their experience, makes for effective team leaders. Finally, future surveys should also assess the impacts of COVID-19 on RNs and NPs. $
David I. Auerbach, PhD External Adjunct Faculty Center for Interdisciplinary Health Workforce
Studies Montana State University College of Nursing Bozeman, MT Max C. Yates Research Assistant Center for Interdisciplinary Health Workforce
Studies Montana State University College of Nursing Bozeman, MT Douglas O. Staiger, PhD John Dickey 3rd Century Professor Department of Economics Dartmouth College Hanover, NH Research Associate National Bureau of Economic Research Cambridge, MA Peter I. Buerhaus, PhD, RN, FAAN,
FAANP(h) Professor of Nursing Director Center for Interdisciplinary Health Workforce
Studies Montana State University College of Nursing Bozeman, MT
NOTE: This research was funded by the Health Workforce Technical Assistance Center, which is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $446,482. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov
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