Facilitating Well-Rounded Clinical Experience for Psychiatric Nurse Practitioner Students

Abstract

There is a steady increase in demand for mental health services and a lack of providers. Recent societal changes resulting from the COVID-19 pandemic have increased these needs. Psychiatric mental health nurse practitioners (PMHNP) are well suited to offer these services. High-quality clinical PMHNP student experiences are based on well-rounded curricula in a variety of clinical settings. Meeting the need for clinical education and finding high-quality preceptors is especially challenging during the pandemic due to the lack of preceptors and access to care for in-person services. Creative approaches are needed to meet student clinical experience needs.

The COVID-19 pandemic has led to economic shut down, disruptions in work and school routines, and social isolation, which increases stress responses and may exacerbate existing mental health and substance use disorder (SUD) problems.¹ There is an increased demand for mental health practitioners to aid the growing number of individuals needing psychiatric care in an already underfunded and overburdened system, which is amplified during the COVID-19 crisis.¹ The need to mitigate COVID-19 infection among mental health service consumers and providers has necessitated the use of telehealth for most services other than those that are procedural.1, 2 Many facilities and providers may be overwhelmed with technological changes, the increase in demand for services, and the need to mitigate infection, leading to limitations for psychiatric mental health nurse practitioner (PMHNP) student clinical care experiences. To meet growing mental health care demands, academic institutions must create educational programs that prepare PMHNPs for the complexities of patient care given the limitations and opportunities presented by the pandemic. Appropriate clinical experiences are integral to a well-rounded PMHNP educational program.

The Role of the PMHNP

Since the expansion of mental health coverage from the Affordable Care Act of 2010, individuals are now able to receive coverage for services for their psychiatric needs. Yet there continues to be a shortage of mental health providers to meet this growing demand. Often, primary care providers (PCP) find themselves delving into the psychiatric care of their patients. It is not uncommon for PCPs such as family nurse practitioners (FNPs) or adult gerontologic nurse practitioners (AGNPs) to prescribe psychotropic medications to their patients. Many PCPs are uncomfortable treating psychiatric patients because they lack adequate experience or knowledge in this area. Additional training is available for FNPs and AGNPs to obtain a postdoctoral or post-master’s certificate in psychiatric mental health nursing, which allows them to obtain national certification in this population foci to expand mental health services.³

The PMHNP role was created to reduce barriers to care for those seeking mental health services. Social determinants of mental health are factors such as education, employment, housing, access to health care services, social support networks, genetics, epigenetics, and psychosocial stressors affect individual and population response to mental health.⁴ By addressing these issues within the curriculum and applying them in clinical settings, PMHNP students can use these principles in an interdisciplinary manner within a nursing framework to meet mental health needs of populations they serve.

The PMHNP enacts the core competencies of the NP in addition to the PMHNP competencies. Educational preparation for PMHNPs may be at either the master’s or doctoral level in the behavioral health care for individuals, families, groups, and communities with psychiatric conditions. These specialists apply the nursing process through diagnostic assessment, psychotherapeutic and psychopharmacological treatment, and evaluation of care.⁵ The importance of this role cannot be overemphasized because PMHNPs, uniquely, can be placed in all areas where behavioral health services are required. Although there are approximately 30,000 nurse practitioners (NPs) who graduate annually, less than 2%, or 600, are PMHNPs, far fewer than are needed to meet the growing demand for services.³

PMHNPs address severe behavioral health (SBH) issues, such as schizophrenia and bipolar disorder, that may not be adequately addressed by PCPs. PMHNPs are knowledgeable about the intricacies of diagnosing and treating individuals who may be overlooked or undertreated by other health professionals because of lack of knowledge or expertise. Patients requiring psychotherapeutic interventions are best suited to the PMHNP who is trained to perform these interventions. Cognitive behavioral therapy, dialectic behavioral therapy, crisis response, solution-focused therapy, strengths-based therapy, and mindfulness techniques are examples of therapeutic interventions that many PMHNPs possess. PCPs may consult and coordinate care for clients with SBH issues by bridging, a method of coordinating care between PCPs and PMHNPs.

Clinical Experiences in Educational Frameworks

PMHNP students must encounter experiences that reinforce what they learn through academic instruction. Simulation, telepsychiatry, school-based learning, inpatient treatment, outpatient treatment, and chemical dependency settings are among the integrative experiences that PMHNP students might encounter. These experiences are all impacted by the pandemic, which place constraints on providers and facilities, limiting the availability for PMHNP student experiences.

Simulation

Simulation experiences enable students to practice skills in a controlled setting, applying what they have been taught and receiving feedback. Simulation for FNPs is provided in most teaching institutions but has not been well developed for PMHNP students, despite the fact that it is a fundamental part of implementing learning and skills taught. Simulation presents students with a variety of scenarios to work through in preparation for situations they may encounter in clinical settings. Via this educational method, students receive support and guidance to hone their skills, allowing them to feel more competent when transitioning to clinical practicum.

It is important to emphasize that simulation does not replace actual live clinical experiences, which are necessary for the PMHNP student to grow. Simulation also cannot be counted for students’ required patient contact hours.⁶ However, faculty can create scenarios that reflect the social isolation that individuals experience due to restrictions and limited interactions with others, which can worsen symptoms of depression, anxiety, substance use, and suicidal ideation or acts. These scenarios provide experiences that students may not encounter given their clinical site placement, the population served at the site, the preceptor to whom they are assigned, and restrictions due to the COVID-19 pandemic.

Cultural factors influence mental health and the unique individual, family, and community responses to illness and treatment. Simulation scenarios can incorporate various cultural factors that PMHNP students need to experience but may not encounter in a given clinical setting. An example is providing PMHNP students with a simulation scenario that involves mental health concerns for transgender individual who is also a member of an ethnic minority.⁷ Such an individual may have an expression and acuity of symptoms that is much different from those of someone who is not a gender or racial minority. Offering a simulated learning experience allows the student to apply cultural humility in an environment that is psychologically safe for the patient and the learner.

Hickie et al⁸ offer a preceptor model, referred to as the “1-minute preceptor model,” that has a framework for simulation using short films that present vignettes of different psychiatric scenarios. Through this model, students can view, discuss, and receive feedback from seasoned clinicians and preceptors, enabling them to contemplate alternative scenarios and reenact simulations with new perspectives.

Various simulations can be developed based on actual or potential cases that students may encounter in clinical settings. These simulations should include scenarios with children, adolescents, adults, and older adults; engaging with them will give students the opportunity to test different therapeutic schemas and receive feedback from peers and faculty. This also allows students to practice using psychiatric screening tools. Using and analyzing psychiatric tools familiarizes students with them, preparing them to comfortably administer these tests in practice.

Screening tools are valuable in helping PMHNPs focus specifically on what is causing the patient distress and allow the clinician to identify areas of stressors that are influencing the individual’s functioning. Symptomatic rating scales offer patients a structured assessment tool to identify psychiatric symptoms and allows clinicians the ability to assess and monitor response to treatment.⁹ Such tools are not diagnostic but are part of the assessment process, although they may not truly capture what the patient is experiencing. An additional benefit for the clinician in the use of screening tools is the comparison of results over time to detect changes in status and the need to implement or revise treatment strategies. It is important to emphasize that these screening tools assist in diagnosis formulation, but PMHP students must be educated on referencing the Diagnostic and Statical Manual of Mental Disorders (5th edition; DSM-5) to ensure the patient meets the criteria for the specified diagnosis.¹⁰

Telepsychiatry

Telepsychiatry has become a necessary and accepted means of reaching those who need mental health services, providing clinicians with a format to reach patients who may not have access to travel or those who have been confined to their homes as has been the case during the COVID-19 crisis. Although evidence supports enhanced concordance with appointments via telehealth, some may have difficulty understanding the use of technology or may not have privacy or access to a computer or smart phone for telehealth visits. These factors may produce barriers to mental health services.¹ Woroch et al¹¹ developed a simulation experience that brought PMHNP and FNP students together to work collaboratively on simulation scenarios through telephone triage experiences. The participating students agreed that telephone triage was a unique way of practicing skills to enhance knowledge and learning.

Clinical faculty can prepare students for tele-mental-health services and working with preceptors who use this format by providing preclinical training on best practices. By providing such information on best practices, students will be well prepared for tele-mental-health encounters, which will enhance the learning experience and the quality of care provided and also reduce the need for the preceptor to provide technology instructions.¹² The student and preceptor are usually in the same geographic location even when performing telehealth services. However, with advances in technology, the student and preceptor may be in the same or different geographic locations, allowing greater flexibility for both to continue their alliance in providing tele-mental-health. Patients may be treated even though they live in a different state than the student and preceptor, providing a rich and varied learning experience.

Developing simulation scenarios that can be implemented via telepsychiatry as a mode of delivering psychiatric services during the time of COVID-19 pandemic can help prepare PMHNP students to address the mental health needs of individuals who are experiencing exacerbation of symptoms during the current societal crisis. Other telepsychiatry simulations can support the educational process of students learning the value of collaboration of care with other professionals.

School-Based Learning

An often overlooked PMHNP educational component is that of clinical rotations in school-based settings. Schools that include mental health services for students can provide early interventions and referrals for more intensive treatment options to support children’s success. This platform not only provides PMHNP students with exposure to children’s and adolescent’s experiences but also reinforces collaboration among teachers, counselors, and psychologists and provides the opportunity for PMHP students to learn how to educate children’s families on their child’s mental health conditions.¹³ In these rotations, PMHNP students can experience various therapies conducted by counselors in school settings as well as participate in individual education plans (IEPs) for students. IEPs support a collaborative approach similar to an interdisciplinary treatment team meeting in which educational needs are addressed to help students thrive.

In a school setting, a behavioral health specialist such as a psychologist may engage in play therapy, cognitive behavioral therapy, and behavior modification therapy. These therapeutic strategies can help improve students’ academic performance and help to promote neuroplasticity. Because many schools are using a remote or online format for students during the current pandemic, telehealth may be a viable option for clinical experiences with this population.

Due to COVID-19 restrictions that have been placed in school settings throughout the United States, PMHNP students who once had the opportunity to gain hands-on experience in working with children and adolescents no longer have this opportunity because most schools use distance learning. The impact on children has also been cited in the literature as students have lost the daily structure that comes with going to school, are more engaged in screen time, experience disruption in mood and increased anxiety, and have become sedentary.¹⁴ This negatively affects their mental health and leads to difficulties in overall functioning, which must be addressed by assessment and early intervention for at risk children and adolescents.

Nursing faculty may find opportunities to work with school counselors by including PMHNP students’ participation in remote-learning sessions with children and adolescents. Preparation for PMHNP students may include simulation scenarios that reflect the impact of COVID-19 restrictions on children, adolescents, and family dynamics and also provide treatment options and expertise in meeting their needs.¹⁴

Inpatient Settings

PMHNP students interested in practicing in a hospital would benefit from exposure to an inpatient psychiatric unit, wherein they can follow a psychiatrist, NP, or therapist in a locked or voluntary psychiatric setting. Such experience allows participation in the different therapeutic groups underway therein, such as chemical dependency groups, cognitive behavioral therapy groups, art therapy groups, mindfulness groups, and family therapy sessions. As PMHNP students’ skillsets and comfort levels increase, they may be encouraged to assist or even lead group therapy sessions with the guidance of their preceptor.

Inpatient settings may include emergency departments (ED) where providers who specialize in mental health offer care for patients who initially arrive at the ED. Patients who present with psychiatric emergencies can be triaged by a behavioral specialist and referred to inpatient psychiatry or the crisis unit as warranted, or they can be treated in the ED before being safely discharged.

Inpatient hospital settings additionally help PMHNP students understand the process of mandatory holds and the acute needs of patients placed in them, as well as exposing students to the care involved in transitioning patients to higher levels of care or to outpatient care that follows acute hospitalization. Although access to inpatient mental health services may be limited during the pandemic, some facilities may allow student participation.

Outpatient Clinics

Outpatient clinics are the most common practice sites for students to gain psychiatric experience. In these clinics, psychiatric students can participate in medication management, individual therapy sessions, interdisciplinary treatment team meetings, and onsite group therapy. Students learn the intricacies of how to comprehensively manage patients’ psychotherapeutic needs including psychiatric medication use for a wide range of patient populations.

Chemical Dependency Programs

Individuals with SUD are at higher risk for COVID-19 related mortality.¹⁵ As the incidence of opioid use disorder (OUD), SUD, and resulting death rates escalate, prompt and effective treatment is imperative. COVID-19 activity restrictions place vulnerable individuals at an increased risk of suffering isolation, unemployment, boredom, and emotional distress leading to increased incidence and severity of SUD.¹⁵

Providing education in telemedicine scenarios can prepare the PMHNP student for treatment of those with SUD and OUD through a technological platform that does not require in-person consultation, protecting this population from potential exposure to COVID-19 while providing a much-needed personal connection. Medication-assisted treatment (MAT) of those with SUD and OUD has been proven effective in harm reduction for this population.¹⁶ PMHNPs are in a unique position to provide this service by obtaining their MAT certification, applying for their X-waiver, and conferring their unique knowledge in treating comorbid psychiatric conditions that are commonly co-occurring in those that have SUD and OUD.¹⁷

Additionally, PMHNP students may gain experience in various types of chemical dependency programs that address the needs of individuals experiencing SUD and OUD, including methadone clinic programs, Alcoholics Anonymous, Narcotics Anonymous, and inpatient detoxification units. PMHNP students, in coordination with their preceptor, can lead support groups that use 12 Step principles, cognitive behavioral therapy, or mindfulness-based therapy to support those who need additional therapeutic intervention through in person or telehealth formats.

Novel Approaches to Enhance Clinical Experience

Clinical experience opportunities should not cease during the COVID-19 pandemic; rather new and creative opportunities should be offered to PMHNP students. Nursing faculty have found it necessary to reach out to psychiatric and nonpsychiatric providers in search of enriching experiences for students that may include nonconventional sites. Many of these sites may not include mental health services, but the addition of such services offers a more comprehensive approach and reduces barriers to care.

For instance, the authors, serving as preceptors, have placed PMHNP students in settings that are traditionally used for FNP students, such as primary care or chronic pain specialty clinics. This allows PMHNP and FNP students to work collaboratively to provide an optimal clinical rotation for both and meet previously unmet mental health needs of the population. Underserved individuals who are affected by COVID-19 restrictions have found support in having their psychiatric needs addressed by a PMHNP while they received primary care or chronic pain treatment.

This model of clinical education clearly supports the necessity and value of interprofessional collaboration. The importance of such collaboration with other providers more effectively addresses the numerous factors that affect the health of the individual, families, and communities.¹⁸ Utilizing this model affords PMHNP students the opportunity to continue their clinical experience during a time when many psychiatric settings are closed to students.

Another opportunity for PMHNP students’ clinical experience that the authors, serving as preceptors, implemented was providing mindfulness classes to patients in a locked-down facility that did allow in-person clinical rotation. A PHMNP student provided such training through Zoom sessions for individuals in the inpatient unit. Patients found these classes invaluable because many of their usual classes and groups were halted due to COVID-19 restrictions. Since the inclusion of mindfulness Zoom sessions, the facility has invited additional PMHNP students to provide similar services. Both of these approaches used nonconventional clinical experiences to meet the needs of students and the population served given the restrictions that limited in person contact.

The Relevance of Connecting With Potential Preceptors

Despite the need for psychiatric providers across the health care spectrum, clinical sites available for PMHNP students are few, and this deficit places a burden on educational institutions that have programs for NPs. This scarcity poses a dilemma for schools prepared to accept and teach at the graduate level. Without established clinical sites, mentorships cannot be developed to support the educational needs of PMHNP students. For students to have clinical experience in various psychiatric settings, nursing schools must establish and nurture relationships with clinical sites.

To identify potential clinical sites and establish working relationships, clinical venues must be explored by a designated clinical coordinator whose sole purpose is to establish relationships for future practitioners in the advanced field of psychiatric nurse practice. Indeed, the value of having an identified clinical coordinator to make these connections with potential preceptors cannot be overemphasized. One reason a nursing school should designate a single contact person to coordinate placements with clinical sites is to avoid burdening potential and actual preceptors with multiple calls, particularly from students, which can diminish a preceptor’s enthusiasm for establishing a connection with a potential academic partner.

Students are encouraged to look proactively at clinical sites of interest and to share potential clinical opportunities with their clinical coordinator. Although having exposure to a variety of mental health settings is ideal for overall learning, PMHNP students who know where they want to practice should inform their clinical faculty about their site preferences. Social connection with potential preceptors may enhance the relationship-building process among students, clinical faculty, and potential preceptors. Connecting with potential preceptors through the use of social media or professional organization meeting attendance may foster relationships between preceptors and students or faculty. Additionally, organization of a faculty-run practice or faculty volunteers who serve in established clinics may provide additional opportunities for student engagement and learning.¹⁹

A positive relationship with the clinical sites that support the PMHNP program is imperative for students’ learning. Faculty and clinical directors must meet with potential preceptors to communicate expectations from both ends. It is also invaluable for faculty to tour clinical sites, speak to potential preceptors, and evaluate whether the clinical sites meet the nursing school faculty expectations. Faculty must clarify the goals and objectives of students in the program with potential preceptors to ensure that the preceptor can meet them. Equally important is that preceptors review the nursing school’s values, goals, and objectives to ensure the preceptors and their institutions foster an environment that aligns so as to enrich the learning of students engaging in clinical rotations at those institutions. Practicing PMHNPs are in the ideal position to share their knowledge and expertise with the new graduates. As such, students gain experience in various settings with a knowledgeable practitioner who can mentor them as a clinician.

Clinical Faculty Responsibilities

In the clinical courses, PMHNP students participate in case discussions with faculty and peers. They receive feedback and challenge one another. Case conferences play an important role in students’ learning, encouraging them to reflect on challenging cases. Supported by faculty and peers, students discover and explore alternative treatment strategies that they may not have considered while at their respective clinical sites and are ultimately encouraged to perform learned skills with confidence.

For faculty members, supporting students in their clinical rotations is essential. This support entails carefully examining the competencies required of PMHNPs and ensuring that each student’s experience supports the development of these competencies. The clinical faculty must actively pair students with compatible preceptors so that students needing additional support are matched with preceptors who can provide this. The clinical faculty also ought to review evaluations from students and preceptors, conduct clinical site visits, and discuss any concerns with students and preceptors.

The Preceptor’s Responsibilities

Preceptors play a key role in facilitating positive experiences for students in achieving their goals and objectives. A preceptor is responsible for observing, teaching, and providing feedback to students regarding their learning. In addition to the knowledge that preceptors provide to students, preceptors may reciprocally gain new knowledge from their students when the students share new guidelines or other information learned in their academic education, which can, in turn, help preceptors stay current in specialty areas.

To successfully transition from learner to practicing clinician, PMHNP students require good role models who can demonstrate professionalism and pass on knowledge and clinical wisdom. National certification demonstrates attainment of the basic knowledge foundation for clinical practice as a PMHNP. The value of certification should be emphasized to students obtaining their state PMHNP license because most states require certification for PMHNPs to practice.

Motivation and Incentives for the Preceptor

Nursing schools that are establishing potential preceptor sites can provide incentives and motivators that can be associated with accepting students in clinical practice. Preceptors can serve as mentors to the upcoming PMHNPs. Morgan et al¹⁹ describe engagement in a graduate nursing project that explores the value and motivation of precepting students. This study demonstrates the value of motivating preceptors and offering incentives to clinicians to precept students.

Incentives that have been identified as motivational for preceptors include the love of teaching, precepting as a tool of recruitment for employment, and affirmation of meeting obligations for qualifying, training, and educating future practitioners.²⁰ Additionally, preceptors can be given affiliate faculty status, access to academic libraries, social connection with other similarly prepared NPs, and access to other areas of the academic experience.

Evidence supporting the value of creating a strong bond between the educational organization and the clinical site by providing syllabi to preceptors for incoming students and streamlining onboarding of students was identified by Todd et al.²⁰ Additionally, to support the relationship between the students and preceptors and the ensuing experience, clinical training modules should be given to preceptors for guidance, including best-practice vignettes and tool kits that preceptors can use with students. Preceptors can also be reassured that students are or will be participating in simulation experiences in preparation for their first clinical rotation, thus increasing their trust and inclination to take on students. Additionally, a student who is well prepared for a clinical practicum will feel more confident in their implementation of learned skills.

Multiple factors may create barriers to precepting students; these include both systems and individual issues. Health care systems are provided financial incentives by the Centers for Medicare and Medicaid Services (CMS) for medical residents but not NPs, which affects available preceptors. Funding for clinical sites that precept students could be provided from the Department of Health and Human Services for nurse education, which could provide an incentive for precepting.¹⁹ Additional factors that affect student precepting include restrictions within some systems to accept students from only certain universities, variation between institutions for the NP student preceptor application processes, lack of physical clinic space, roll out of new electronic health record systems, lack of preceptor incentives to take students, preceptors’ time constraints due to heavy work flows, and preceptors feeling bombarded with additional work involved in teaching.¹⁸ Given these constraints, reminding preceptors of the value of having students in their practice that include the ability to educate the next generation of NPs, the value that properly educated NP students can add to the clinical setting, and the new clinical ideas and perspectives that NP students can offer seasoned preceptors.

The COVID-19 pandemic has caused shifts from in-person services to primarily telehealth for most nonemergent care to reduce infection transmission. Although this shift may increase access to care for some patients and providers, others may experience increased barriers and stressors. Some preceptors may be less likely to accept NP students, and others may be more likely to because factors such as space and geographic location are eliminated. NP faculty must work closely with preceptors and provide telehealth training for NP students so that they possess the needed technology skills when precepting opportunities arise.

Preceptors and students should be given opportunities to evaluate their relationship at their assigned clinical site. Such evaluation gives both parties the opportunity to identify positive or negative factors that are working for or against students’ chances to gain meaningful experiences. To evaluate the effectiveness of mentorship, surveys should be conducted with preceptors and students. This process of evaluation provides an opportunity to give feedback to the student and preceptor but also to NP faculty so that modifications can be made to strengthen the relationship between the clinic and the university.

Summary

The need for mental health services, including those provided by PMHNPs, is increasing and especially so given the current COCID-19 pandemic and the mental health challenges presented from it. However, educational opportunities for PMHNPs are sparse because of the limited availability of clinical sites; the scarcity of experienced, knowledgeable PMHNPs who are willing to precept a student; and the many challenges presented by the pandemic. Presenting the positive aspects of precepting to potential preceptors is essential because many may be unaware of the value of precepting. Exploring alternative clinical experiences such as telehealth may expand student experiences and provide excellent learning opportunities. Nursing schools must have clinical coordinators who can market their NP programs and establish connections with various sites to better facilitate the clinical experience needed by psychiatric NP students.

Clearly, PMHNP students must be given ample experience in diverse psychiatric settings to help them find the areas of psychiatric nursing they find most rewarding. Unless the opportunity for clinical rotations is broadened, the deficit of well-rounded educational experiences for PMHNP students will persist, and the need for mental health services will remain unmet. By establishing connections in various psychiatric facilities and preparing students for these experiences, nursing school faculty members can provide students with opportunities for this invaluable experience.

Biographies

Joan Fraino, DNP, FNP-C, PMHNP-BC, is an adjunct professor, University of San Francisco, San Francisco, CA

Nancy Selix, DNP, CNM, FNP-C, is an associate professor, University of San Francisco, San Francisco, CA, and can be contacted at nwselix@usfca.edu