The American Psychiatric Nurses Association
Journal of the American Psychiatric
Nurses Association
2020, Vol. 26(1) 97101
The Author(s) 2019
Article reuse guidelines:
DOI: 10.1177/1078390319886357
Discussion Paper
Mental illness affects an estimated 20% of the U.S. population aged 13 years and older per year, totaling $467 billion in estimated direct and indirect costs annually
(Center for Behavioral Health Statistics and Quality,
2015; Insel, 2015; National Institute of Mental Health,
2002). Overall, mental health care access is limited as
less than half of the individuals with a mental illness
receive professional treatment (Center for Behavioral
Health Statistics and Quality, 2015; Insel, 2015; National
Institute of Mental Health, 2002) . In nonmetro rural
communities (gross population < 20,000), about 6 million persons have mental illness, and suicide rates are
higher for adults and usually double for youth in rural
areas versus urban areas (Fontanella et al., 2015; Rural
Health Information [RHI] Hub, 2017e). Appropriately,
mental health is ranked as the fourth major priority, while
substance abuse is ranked fifth in the Rural Healthy
People 2020 national priorities (Bolin et al., 2015).
Despite the significant need, rural health care systems are
currently unable to meet the mental health needs of the
communities that they serve.
Few inpatient psychiatric and substance abuse facilities are in rural communities, and most acute psychiatric
patients transfer to metropolitan inpatient psychiatric
facilities (Agency for Healthcare Research and Quality,
2015; RHI Hub, 2017b). This situation created a national
crisis, boarding psychiatric patients in rural emergency
departments up to 18 days before transferring, often causing extreme patient distress and administrative issues
with poor resource management (Joint Commission,
2015). Meanwhile, many rural people with opioid use
disorder may be waitlisted months or even years for in their own community or opt to travel to receive treatment in larger cities
(Sigmon, 2014). The rural patient receiving care in a metropolitan area can be complicated as admissions and discharges from metropolitan facilities is a challenging
undertaking for interdisciplinary teams and transportation services (RHI Hub, 2017b). Additionally, care coordination is usually complex and does not have enough
qualified personnel involved for a smooth process (RHI
Hub, 2017b).
In the outpatient rural health setting, most people
receive psychiatric care from their primary care provider
due to a great shortage of psychiatric specialists and
886357JAPXXX10.1177/1078390319886357Journal of the American Psychiatric Nurses AssociationFinley
Brooke A. Finley, MSN, PMHNP-BC, RN-BC, University of Arizona,
Tucson, AZ, USA; The Meadows Behavioral Health, Wickenburg, AZ,
USA; FasPsych, LLC, Scottsdale, AZ, USA; Grand Canyon University,
Phoenix, AZ, USA
Corresponding Author:
Brooke A. Finley, DNP/Ph.D. student at the University of Arizona
College of Nursing, 1305 N. Martin Avenue, PO Box 210203, Tucson,
AZ 85721, USA.
Email: [email protected]
Psychiatric Mental Health Nurse
Practitioners Meeting Rural
Mental Health Challenges
Brooke A. Finley1
OBJECTIVE: To describe the current rural mental health system crisis in the United States and how psychiatric
mental health nurse practitioners (PMHNPs) can holistically mitigate this systemic issue. METHOD: Respective
to the objective, relevant literature is reviewed. RESULTS: PMHNPs have successfully increased access to care
in underserved rural communities by practicing at the fullest extent of their scope without mandated supervision,
utilizing telepsychiatry practice, while expanding PMHNP rural mental health education and research to meet and
absolve pressing rural mental health challenges. CONCLUSIONS: Current evidence supports that rural mental
health care improves when PMHNPs have full scope of practice, utilize telepsychiatry, engage in related scholarly
activity, and have formalized education and training for rural health care delivery, which collectively answer the
professional and moral call serving the underserved rural population with mental illness.
rural nursing, mental health, nurse practitioners, scope of practice, telepsychiatry
98 Journal of the American Psychiatric Nurses Association 26(1)
therapists (Kverno & Kozeniewski, 2016; Lynm &
Bonham, 2013; RHI Hub, 2017e). Yet there is a lack of
primary care providers in rural primary care as well,
many of which lack comprehensive, in-depth mental
health training (Petterson, Phillips, Bazemore, & Koinis,
2013). Issues are further complicated as rural persons are
less likely to have a primary care provider and less likely
to receive regular preventative care (Agency for
Healthcare Research and Quality, 2015; Matthews et al.,
2017). Furthermore, those with mental health issues are
less likely to have health insurance and are more likely to
miss their health care appointments (RHI Hub, 2017e).
These problems coupled with general rural communities
problems like poverty, homelessness, social stigma, low
health insurance rates, long travel distances, and lack of
public transportation services, make this population difficult to serve, creating low incentives for rural clinics to
provide mental health services, especially since reimbursement rates are low (Lynm & Bonham, 2013; RHI
Hub, 2017e).
Most rural health care services have multiple financial
challenges (RHI Hub, 2017d). In response, incentive programs were created including the Affordable Care Act,
which increases service payments, favorable reimbursement adjustments, and increasing ancillary service delivery payments (Barker, Kemper, McBride, & Meuller,
2016; RHI Hub, 2017d). The Centers for Medicare and
Medicaid Services (CMS) made the Critical Access
Hospital designation, which keeps rural acute care hospitals open by reducing financial vulnerability after meeting specific qualifications (RHI Hub, 2017a). Critical
Access Hospitals receive an additional 1% reimbursement of services, increased hospital network connections
for smoother transfers, staffing services, more funding
and grant opportunities, and increased educational and
technical services (RHI Hub, 2017a). Furthermore, CMS
created the Rural Health Clinic designation, where nurse
practitioners and physician assistants are present at clinics at least 50% of all working hours to provide more primary care and laboratory services (RHI Hub, 2017c).
Last, the Federal Office of Rural Health Policy of the
Health Resources and Services Administration implemented six specialized rural hospital programs to support
existing rural hospitals staying open after 80 rural hospitals unexpectedly closed between 2010 and 2016 (Health
Resources and Services Administration, 2017).
Many of these programs were implemented after the
Institutes of Medicines 2001 Crossing the Quality Chasm
report, in which rural community health care needs were
highlighted and quality, safety, patient-centered care, timeliness, efficiency, equity, and effectiveness were aimed
for improvement after poor outcomes were identified
from personnel shortages, lower rural persons self-care
practices, specialist access paucities, and low financial
resources in the rural health care systems (National
Academies of Sciences, Engineering, and Medicine, 2005;
RHI Hub, 2017d). Collectively, there are four national
rural mental health care policy recommendations, which
include reducing the mental health workforce gap using
loan repayment in critical-needs areas, Medicaid reimbursement for designated serious mental illness health services, evidence-based practice opportunities, and integrated
mental health and primary care services (Olfson, 2016).
However, despite incentives, many rural health care service providers and facilities are not willing to engage in
federal programs because of their ideological and practical
concerns about reimbursement, despite their knowledge of
the programs and financial strain (Ostrow, Steinwachs,
Leaf, & Naeger, 2017; Watanabe-Galloway, Madison,
Watkins, Nguyen, & Chen, 2015). The various requirements, certifications, and challenges associated with
accepting CMS-funded populations, which have more
medical issues associated with poverty and are generally
higher acuity, deter many rural facilities from participating
(Beronio, Glied, & Frank, 2014).
Psychiatric Mental Health Nurse
Practitioner Solutions for Rural
Mental Health
Given the state of rural mental health affairs, PMHNPs
and physician colleagues are equipped to organize and
advocate politically for PMHNP full scope of practice
(i.e., independent practice) and challenge constraining
mandated physician supervision (Andrilla, Patterson,
Moore, Coulthard, & Larson, 2018; Chapman, Toretksy,
& Phoenix, 2019; de Nesnera & Allen, 2016; Delaney
et al., 2018; Spetz, Skillman, & Andrilla, 2017). Mandated
supervision is financially costly, falsely justifies unequal
reimbursement for comparable work, supports inequitable professional relations, increases administrative burden, and overall decreases mental health access to
services from all involved providers (Chapman et al.,
2019; de Nesnera & Allen, 2016). While political efforts
for PMHNP independent practice rights may be slow and
painstaking in the workplace and courthouse, collaborative strategic efforts have been effective in the past (de
Nesnera & Allen, 2016).
States with full-practice rights for PMHNPs demonstrate increased service provision to vulnerable and rural
populations and associated cost savings, improved selfreported mental health among patients, and decreased
mental healthrelated mortality (Alexander & Schnell,
2019; Martsolf, Auerbach, & Arifkhanova, 2015;
Phoenix, Hurd, & Chapman, 2016; Xue, Ye, Brewer, &
Spetz, 2016). Of note, PMHNPs with independent practice rights working in community mental health clinics
provided twice as many mental health visits and treated
Finley 99
more patients compared with colleagues in states who did
not have independent practice rights and can combat the
opioid crisis after obtaining a prescribing waiver (e.g.,
buprenorphine) once they have completed a 24-hour
training (Andrilla et al., 2018; Substance Abuse and
Mental Health Services Administration, 2017; Tierney,
Finnell, Naegle, LaBelle, & Gordon, 2015; Yang et al.,
2017). Overall, the PMHNP workforce is growingit is
essential that state policies reflect practice autonomy,
Drug Enforcement Administration prescribing rights,
acute care admitting privileges, expanded clinical roles,
and independent billing to support PMHNP presence, satisfaction, and position longevity in rural areas (Chapman,
Phoenix, Hahn, & Strod, 2018; Delaney, Drew, &
Rushton, 2019; Owens, 2019; Spetz et al., 2017).
Beyond legislative restrictions, geographic boundaries
are overcome as PMHNPs deliver rural inpatient and outpatient psychiatric care via telepsychiatry, defined as
using teleconferencing technology to provide mental
health care and healing at a distance, with high user satisfaction and efficacy (Finley & Shea, 2019; Mehrotra
et al., 2017; RHI Hub, 2017e). Telepsychiatry services
are generally covered in rural areas by commercial and
federal payers (Finley & Shea, 2019). Telepsychiatry
consultations can be feasibly adopted in established rural
primary care settings; meanwhile, on-site primary care
nurse practitioners can earn a postmaster certification in
psychiatric mental health online to expand their practice
for an integrated provider role without having them leave
the rural setting for further education (Fortney et al.,
2015; Kverno & Kozeniewski, 2016).
There are numerous successful academic and federal
telepsychiatry partnerships with a rural focus, and associated research is being funded by interested federal, academic, and private agencies (Britson, Arends & Gibson,
2016; Finley & Shea, 2019). PMHNPs are equipped to
increase and influence telepsychiatry implementation and
adoption by focusing on program development, practice
legislation, academic partnerships, sustained infrastructure, and championing integrated care models (Britson,
Arends, & Gibson, 2016; Delaney et al., 2018; Fathi,
Modin, & Scott, 2017). PMHNPs engaged in telepsychiatry practice, especially with doctoral preparation, can
implement evidence-based practice guidelines and can
conduct quality improvement projects, program evaluations, and lead and participate in respective research
(Zaccagnini & Pechacek, 2019).
Given the shortage of PMHNP preceptors, academic
institutions that have partnered with rural PMHNPs can
expand their educational presence using telehealth technology to remotely preceptor nurse practitioner students,
providing rural-specific training to future providers and
overcoming distance barriers to retain preceptors
(Morgan, Brewer, Buchhalter, Collette, & Parrot, 2018;
Rutledge et al., 2017). Telehealth technology also allows
for remote site clinical supervision bypassing barriers
like supervisor travel and time and can provide standardized rural telehealth simulations (Schweickert et al.,
2018; Tyson, Brammer, & McIntosh, 2019). At this time,
telehealth didactic, simulation, and clinical education
should be intentional and standardized for PMHNP students so that they employ the skills and training necessary
to be successful, compassionate providers in this rapidly
expanding modality (Baird, Whitney, & Caedo, 2017;
Britson, Arends, & Gibson, 2016; Finley & Shea, 2019;
Strudwick, et al., 2019; Tyson et al., 2019). Last, expert
faculty can also guide their students in support of scholarly projects (e.g., Doctorate of Nursing Practice project,
dissertation, capstone, thesis) focusing on telepsychiatry
and rural mental health (Moran, Burson, & Conrad,
While there are inherent limitations in reviewing a
select sample of relevant literature, it is undoubtable that
rural mental health needs remain high and the environment is challenging (RHI Hub, 2017e). Current evidence
supports that rural mental health care improves when
PMHNPs have full scope of practice, utilize telepsychiatry, engage in related scholarly activity, and have formalized education and training for rural health care delivery,
which collectively answer the professional and moral call
in serving the underserved rural population with mental
illness (Pearson et al., 2015; RHI Hub, 2017e).
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
The author received no financial support for the research,
authorship, and/or publication of this article.
Brooke A. Finley
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You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

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We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment Help Service Works

1. Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2. Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3. Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4. Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

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Basic features
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  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
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  • Overnight delivery
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Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

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Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

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Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

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Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

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