Individual and family psychotherapy

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Based on the reading assignment this week, respond to the two following questions: 

1-     What can we do as PMH-APRNs to close the existing disparities in Mental Health?

2-     Do you consider there is a stigma associated with specializing in PMH? 

The student must answer the graded discussion with a substantive reply to the graded discussion question(s)/topic(s) posted by the course instructor by Thursday, 11:59 p.m. Eastern Time. Two scholarly source references are required unless stated otherwise by your professor. 

The student provides a substantive response to the discussion question or topic on Thursday day and posts a minimum of two additional responses to peers on another day(s). The answers to classmates must be posted by Sunday, 11:59 pm Eastern Time. We expect each student to participate in the discussion board respectfully. 

Remember that a new discussion rubric was approved by the professors, committee members, and most of the students. Please review the rubric before posting to ensure a maximum of points. 

Here are the categories of the new discussion rubric:

Initial Post relevance to the topic of discussion, applicability, and insight. (20%)

Quality of Written Communication Appropriateness of audience and word choice is specific, purposeful, dynamic, and varied. Grammar, spelling, punctuation. (20%)

Inclusion of APNA standards essentials explored in the discussion as well as the role-specific competencies as applicable. (10%)

Rigor, currency, and relevance of scholarly references. (Use articles that are under 5 years old). (20%)

Peer & Professor Responses. The number of responses, and quality of response posts. (20%)

Timeliness of the initial post and the answers to the peers. (10%)

Psychiatric-Mental Health Nurses
Are Key to Addressing the Nation’s
Mental Health Crisis

New Data Sheds Light on Solutions to
Address Surging Demand & Provider Shortages

Executive Summary:
Escalating demand and increasing gaps in equity
and access to quality mental health care in the
United States have been exacerbated by the
impact of the COVID-19 pandemic. Psychiatric-
mental health (PMH) nurses can help fill these
critical gaps in the mental health care system,
but an aging workforce and restrictive policies
continue to clash with the need to expand access
to care. This report explains the surging mental
health crisis in the U.S., barriers to addressing
the crisis, and the latest findings about under-
recognized health care professionals whose skills
and expertise make them essential to addressing
this national mental health emergency.

www.APNA.org

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

THE U.S. IS EXPERIENCING A
MENTAL HEALTH STATE OF EMERGENCY

W hen tornadoes, hurricanes, and other natural disasters
occur, the devastation and long-term impacts are
readily visible. In contrast, over the last 2 decades, the

nation’s mental health crisis has quietly gained momentum with
equally devastating results to individuals, families, schools, and
communities in rural areas, small towns, suburbs, and large cities.
In recent years, the COVID-19 pandemic added more fear, stress,
isolation, depression, financial concerns, and mental exhaustion
on top of already rising rates of mental health and substance use
challenges in our communities.

Exponentially rising rates of mental health and substance use
disorders are significant challenges, even more so in the context of
a significant shortage of mental health professionals that impedes
access to care. As a result, each year, millions of Americans do not
receive the mental health and substance use treatment they need.

What does this mental health crisis look like? The lack of access
to mental health care and resulting health inequities have per-
meated nearly every area of American life and broadly increased
negative outcomes. (Health equity is defined as the right to access
quality health care for all populations regardless of the individual’s
race, ethnicity, gender, socioeconomic status, sexual orientation,
or geographical location.)

Whole health begins with mental health. Mental health is foun-
dational to overall health and therefore vital to the health of the
nation. Policymakers and health care stakeholders must come
together to take the actions needed to deliver substantially more
accessible, high-quality care to all people with mental health and
substance use challenges in all communities across the country.

The following report details the rising rates of patients in need;
documented shortages of professionals needed to provide
adequate treatment; the ongoing impact of the lack of access
and equity in treatment; and recommendations to allow for the
expanded use of psychiatric-mental health (PMH) Registered
Nurses (RNs) and Advanced Practice Registered Nurses
(APRNs) to fill these growing gaps in mental health care.

1

WHOLE HEALTH BEGINS

WITH MENTAL HEALTH.

MENTAL HEALTH IS FOUNDATIONAL

TO OVERALL HEALTH AND

THEREFORE VITAL TO THE

HEALTH OF THE NATION

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

State of the Nation:
MENTAL HEALTH URGENCY
AMONG ADULTS
Even before the COVID-19 pandemic, the U.S. health care system
struggled to meet the needs of an escalating mental health crisis.
Increasing demand for mental health services has grown annually,
overwhelming available mental health professionals.

Access to comprehensive mental health services is an essential
precursor to the delivery of equitable, high-quality mental health
care. Unfortunately, both access to care and equity in mental
health care have been steadily decreasing for decades.

Americans consistently lack the same access to mental health
providers as they have to other health care providers, all while the
prevalence of mental health challenges continues to exponentially
increase.

Prior to COVID-19, one in ten adults reported symptoms of an anxi-
ety and/or a depressive disorder. However, during the COVID-19
pandemic, that number rose to 4 in 10 adults. The latest Sub-
stance Abuse and Mental Health Services Administration (SAM-
HSA) data further provide a snapshot of current rates of mental
illness in the U.S.:

• 73.8 million Americans are experiencing mental illness or
substance use disorders.

• 52.9 million American adults are experiencing any mental
illness (AMI*).

• 14.2 million are experiencing serious mental illness
(SMI**), with percentages highest among adults younger
than age 49.

Additionally, the CDC recently reported concerning increases
in suicide rates among young adults, American Indians, Alaska
Natives, Black Americans, and Hispanic Americans – populations
that previously had much lower rates of suicide – expanding ongo-
ing concerns about mental health equity and access to care in the
U.S.

PMH nurses are key to addressing this mental health urgency
among adults.

SYSTEMIC
DISPARITIES
WITHIN MENTAL
HEALTH CARE
BY RACE, SEXUAL
ORIENTATION,
GENDER, & INCOME

Black and Latinx Americans
are more likely to experi-
ence persistent symptoms
of emotional distress than
White Americans.

Despite this:
Just one in three Black
adults who need mental
health care receives it.

Among Latinx Americans,
just 33% receive mental
health care, compared with
43% of White Americans.

LGBTQ+ individuals are
more than twice as likely as
non-LGBTQ+ individuals to
experience a mental health
disorder.

Transgender individuals are
nearly four times as likely to
experience a mental health
disorder than cisgender
individuals.

Those living in high-poverty
neighborhoods have been
shown to experience signifi-
cantly greater symptoms of
emotional distress.

“How to Transform the U.S. Mental Health
System” McBain et al., 2021 p. 27

*Any Mental Illness (AMI) is defined as individuals having any mental, behavior, or emotional
disorder in the past year that met DSM-5-TR criteria (excluding developmental and substance use
disorders).

** Serious mental illness (SMI) is defined by someone older than 18 having within the past year a
diagnosable mental, behavior, or emotional disorder that causes serious functional impairment
that substantially interferes with or limits one or more major life activities.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

State of the Nation:
MENTAL HEALTH URGENCY
AMONG CHILDREN & ADOLESCENTS

Before COVID-19, the CDC reported mental
health challenges were the leading cause of
disability and poor life outcomes in young people,
with up to 1 in 5 children ages 3 to 17 in the U.S.
experiencing a mental, emotional, developmen-
tal, or behavioral disorder.

A recent U.S. Surgeon General’s Advisory
highlights the urgent need to address the
nation’s mental health crisis among young
people after the initial onset of the pandemic.
The number of high school students reporting
persistent feelings of sadness or hopeless-
ness increased by 40% to more than 1 in every
3 students. And the rate of suicide among those
aged of 10 to 24 years increased by 57%.

In November 2021, the American Academy of
Pediatrics, American Academy of Child and
Adolescent Psychiatry, and the Children’s
Hospital Association declared a national state
of emergency in child and adolescent mental
health.

The pandemic impacted nearly every aspect
of the lives of youth, and the Surgeon General
reports that our most vulnerable youth popula-
tions – those with disabilities, racial and ethnic
minorities, LGBTQ+, low-income, those in rural
areas, those in immigrant households, those
involved with the child welfare or juvenile justice
systems, and/or homeless – were impacted most
severely.

PMH nurses are key to alleviating this
mental health urgency among children
and adolescents.

“Mental health challenges in
children, adolescents, and young
adults are real and widespread…
The COVID-19 pandemic further
altered their experiences at home,
school, and in the community, and
the effect on their mental health
has been devastating. The future
wellbeing of our country depends
on how we support and invest in
the next generation.”

 — U.S. Surgeon General
Vivek Murthy

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

A NATIONAL EPIDEMIC
OF SUBSTANCE USE DISORDERS

A substance use disorder (SUD) is a mental disorder that affects a person’s brain and behavior,
leading to a person’s inability to control their use of substances such as legal or illegal drugs,
alcohol, or medications. And, approximately half of those who experience a mental illness during
their lives will also experience an SUD, and vice versa.

In 2017, the Department of Health and Human Services (HHS) declared a public health emer-
gency and implemented a plan to address the nation’s devastating opioid crisis. More recently,
in a June 2020 CDC survey, 13% of American adults reported new or increased substance use due
to COVID-19-related stress. Early 2020 data also show that drug overdose deaths were particularly
pronounced from March to May 2020, coinciding with the start of the COVID-19 pandemic-related
lockdowns.

SAMHSA reports demonstrate the continued growing impact of SUDs on American adults and young
people. The latest data show:

• 40.3 million Americans aged 12 or older experienced a substance use disorder (SUD) in the
past year.

• 6.5 million experienced both an alcohol use disorder and an illicit drug use disorder.
• 5.1 million adolescents aged 12 to 17 had either a SUD or a major depressive episode (MDE)

in the past year, while 644,000 adolescents had both an MDE and an SUD in the past year.

All Americans who experience SUDs must have equitable access to mental health providers with
expertise in SUD care and treatment, including Medication for Addiction Treatment (MAT) options.

A 2021 Psychiatry Online
report urgently called for a
“rapid and substantial” scaling
up of access to effective
SUD treatment to address
the ongoing opioid crisis
and continually rising rate of
overdose deaths. For example,
more than 100,000 overdose
deaths occurred in the
12-month period that ended
in January 2022.

PMH nurses are key to
tackling the national epidemic
of substance use disorders.

12 Month-ending Provisional Counts of Drug
Overdose Deaths: United States

2015 2016 2017 2018 2018 2019 2021 2022

60,000

120,000

REPORTED
PROJECTED

Based on data available for analysis on: June 5, 2022
Source: CDC

0

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

MILLIONS OF AMERICANS
ARE LEFT UNTREATED EACH YEAR
The rates for adults and young people experiencing mental health and substance use challenges have
continued to trend upward, while the percentage of those who report an unmet need for treatment
has also increased every year since 2011.

Americans continue to find it difficult to access mental health and substance use care for several
reasons:

• Provider Shortages: People lack the same access to mental health providers as they have for
other health care providers – more than one-third of Americans live in areas with a shortage
of providers. In some states, more than 80% of the population live in a mental health provider
shortage area.

• Health Insurance Does Not Cover Most Treatment: If a patient is able to find a mental
health professional for treatment, they are often forced to go out-of-network. A 2019 report
found that a mental health office visit is more than five times more likely to be out-of-network
than a primary care appointment.

• High Out-of-Pocket Costs: Because many available providers rarely accept Medicare,
Medicaid, or private insurance, ongoing mental health care often requires a patient to make
a financial commitment to pay significantly higher out-of-pocket costs than other types of
primary or specialty care.

Increased demand generated by the impacts of the COVID-19 pandemic has caused the treatment
gap in the U.S. to increase. The National Institute of Mental Health (NIMH) reports that in 2020,
fewer than half of American adults with a mental illness (46%) were able to receive the mental
health services they needed.

Data from SAMSHA further illustrates the enormous numbers of Americans with an unmet need for
mental health and substance use support. In 2020

• Among the 67.1 million American adults experiencing mental illness, only 41.4 million
received mental health services.

• Only 41.6% of American adolescents experiencing a major depressive episode received
treatment.

• Only 1.4% of Americans aged 12 or older experiencing a SUD received any substance use
treatment.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

Within this widespread unmet need for mental health and substance use care, 77% of counties
across the U.S. are experiencing severe shortages of mental health professionals. Reports
published annually by the Kaiser Family Foundation provide a deeper view into these mental health
provider shortage areas. As of September 2021:

• 41 states are reported to meet less than 40% of the mental health need in their state.
• 27 states are reported to need more than 100 additional mental health care providers just to

reach a ratio of 30,000 patients to 1 mental health provider in those communities.
• 25 states have more than 100 designated mental health professional shortage areas in their

state.

PMH nurses are key to expanding access to care across the country.

Location Percent of
Need Met

Total Mental
Health Care HPSA

Designations

Population of
Designated

HPSAs

Practitioners Needed
to Remove

HPSA Designation

Arizona 8.5% 233 3,478,236 227
Delaware 11.6% 13 289,347 25
Alaska 12.1% 321 414,461 21
Missouri 12.2% 270 2,311,813 159
North Carolina 13.0% 204 3,917,688 221
West Virginia 13.0% 110 788,226 90
Hawaii 14.1% 32 496429 28
Washington 16.2% 179 3,206,169 154
Tennessee 16.3% 73 3,464,471 261
New Mexico 18.2% 94 1,619,974 86
New York 18.8% 202 6,369,714 411
Connecticut 19.0% 44 1.542.562 84
Maryland 19.4% 63 1,709,025 101
Maine 19.7% 68 399,337 31
Florida 21.0% 235 8,703,183 509

10 – 70

72 – 126

152 – 242

250 –578

Mental Health Professional
Shortage Areas by State

Source: Kaiser Family Foundation, Mental
Health Care Professional Shortage Areas
as of September 2021.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

WE MUST EXPAND
THE MENTAL HEALTH WORKFORCE

W ith each passing year, the need to attract and train an
expanded workforce of mental health professionals
to address patient access and equity becomes more

urgent. The ongoing demand for care has significantly outpaced
the impact of efforts to address problems of access, leaving
millions of Americans without the help they need.

Untreated mental health challenges have set the nation on a
precarious trajectory – linked to social risks, including home-
lessness, low/poor education, and increased rates of substance
use. The need to expand the workforce of qualified mental health
professionals has never been greater.

To help address the nation’s shortage of mental health
providers, SAMHSA reports the need for more than half a
million additional psychiatric-mental health (PMH) nurses
to reach “merely adequate access” to mental health and
substance use disorder care.

It’s clear that the future well-being of the country rests on the
shoulders of how well we address this ongoing and expanding
mental health emergency. PMH nurses are crucial players in the
psychiatric-mental health workforce; expanding their numbers and
roles will expand patient access to quality mental health care.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

The APNA Workforce Survey:
THE VITAL ROLE OF PSYCHIATRIC-MENTAL
HEALTH NURSES

For 20 consecutive years, nursing has been consistently rated the most trusted health care profes-
sion, according to an annual Gallup Poll. Americans greatly value the expertise, commitment, and
professionalism that nurses provide.

Psychiatric-mental health Registered Nurses (PMH-RNs) and Advanced Practice Registered Nurses
(PMH-APRNs) represent the second largest group of mental health professionals in the U.S. PMH-
RNs and PMH-APRNs play pivotal roles in advancing health equity and providing access to profes-
sional mental health and substance use services to diverse patients across the nation.

All PMH nurses, whose practice is guided by nursing theory and process, are rigorously educated to
provide mental health and substance use care to patients. They are trailblazers in new and emerging
models of inter-professional care that place the patient at the center of the care delivery system to
drive positive outcomes and foster recovery from mental health disorders.

To address the expanding gaps in mental health care outlined above, stakeholders in nursing and
mental health must come together to recruit a new and more diverse PMH nursing workforce. We
must also ensure the deep skillsets and vital roles of PMH nurses are fully utilized to provide Ameri-
cans increased and equitable access to mental health and substance use care.

As a first step, to more accurately understand the characteristics of the current PMH nursing
workforce, identify areas in need of growth, and expand initiatives to help address the shortage of

mental health and substance use professionals, the American
Psychiatric Nurses Association (APNA) conducted the first
comprehensive research into the PMH nursing workforce.

Developed by an APNA PMH Nursing Workforce Task Force, the
APNA workforce survey was administered to PMH-RNs and PMH-
APRNs from 10/21/2020 to 5/13/2021. The PMH-RN survey was
completed by 4,088 professionals and the PMH-APRN survey was
completed by 5,158 professionals. The combined response rate for
the surveys was 12.1%.

Past national-level analyses of the mental health workforce have
failed to appreciate or incorporate the full scope of PMH nurses’
role and capabilities within psychiatric-mental health care. This
robust report should inform future analyses with reliable and

9

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

comprehensive data, granting
a full picture of the scope and
impact of the PMH nursing
workforce.

The lack of understanding of
PMH nursing among policy-
makers and stakeholders
has hampered the profession
from making its full impact
on the state of mental health
care. Today, more than 148,000
PMH nurses are providing
high-quality mental health and
substance use services across
the U.S.

While PMH-RNs and PMH-
APRNs have the skills and
qualifications to expand access
and equity in mental health
care all across the U.S., more
practicing PMH nurses are
needed, and they must be
utilized to the full extent of
their education and training.

Current Numbers of Some
Key Mental Health Providers

Psychiatrists 38,381 (by 2024)

Psychologists 106,000

Physician
Assistants

2,235

Psychiatric
Pharmacists

996

PMH Nurses
109,000 PMH-RNs

39,354 PMH-APRNs

10

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

WHAT DO PMH NURSES DO?

PMH nurses are psychiatric-mental health care professionals
who practice according to rigorous licensing and credentialing
standards. Their nursing training emphasizes preventive
person-centered care and recovery. PMH nurses form strong
therapeutic relationships with people experiencing mental
health and/or substance use disorders, and often work closely
with patient families as well.

Working broadly within health care systems with an orientation
toward innovation, PMH nurses consistently seek new oppor-
tunities for growth, development, and creative solutions to
improve the delivery of care and meet the unique needs of the
communities they serve.

Two Types of PMH Nurses:
RN & APRN

Psychiatric-Mental Health Registered Nurses (PMH-RN)

PMH-RNs work with diverse individuals, families, groups, and communities to
assess mental health, and develop a diagnosis and an individualized plan of care.
PMH nurses maintain current knowledge of advances in genetics and neuroscience
and their impact on psychopharmacology and other treatment modalities.

PMH-RNs engage in a broad array of nursing activities including health promotion
and maintenance; intake screening, evaluation, and triage; case management;
teaching self-care activities; administration of psychobiological nursing interven-
tions and the monitoring of medications and effects; crisis intervention and stabili-
zation efforts; psychiatric rehabilitation; and culturally appropriate interventions that
assist in a patient’s recovery. PMH-RNs also work to educate patients, families, and
communities and coordinate care between other needed health care professionals
and the caregivers for the patient.

PMH-RNs are licensed by state boards of nursing and may be certified in psychiat-
ric-mental health by the American Nurses Credentialing Center (ANCC). According
to the ANCC, the requirements for the PMH-RN certification include an RN license,
2 years of practice as a full-time registered nurse, and a minimum of 2,000 hours of

Definition of Psychiatric-Mental
Health Nursing

Psychiatric-mental health (PMH)
nursing promotes integrated
and comprehensive health and
wellness through prevention and
education, as well as assessment,
diagnosis, care, and treatment of
the full range of PMH disorders,
including substance use disorders,
across the life span. PMH nurses
provide care at the individual, fam-
ily/relationship, community, and
societal levels to promote well-be-
ing and quality of life, as well as to
sustain positive health outcomes.

– Psychiatric-Mental Health Nursing: Scope
and Standards of Practice (2022)

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

clinical practice and 30 hours of continuing education – both in PMH nursing and
within three years.

PMH-RNs are essential to ensuring patient access to mental health care as they
actively provide patient care in inpatient, outpatient, and community health clinics
–at the bedside and in management.

Psychiatric-Mental Health Advanced Practice
Registered Nurses (PMH-APRNs)

PMH-APRNs provide the full range of services that constitute psychiatric-mental
health care and treatment. They hold advanced master’s or doctoral degrees,
national certification, and additional licensure (based on their state board of nursing
requirements). The additional education, clinical experience, and training enables
PMH-APRNs to assess, diagnose, and prescribe medication for mental health
disorders; provide psychotherapy, consultation and liaison services; oversee case
management; and more.

PMH-APRNs practice as Clinical Nurse Specialists (CNS) or Nurse Practitioners
(NP), though their titles can vary by state. Some PMH-APRNs obtain doctoral
degrees in psychiatric-mental health nursing.

The role of a PMH-APRN often complements that of a psychiatrist, psychologist, or
social worker as part of a mental health care team.

PMH-APRNs work in a wide variety of settings – outpatient, ambulatory, emergency
departments, and hospitals. Others own private practice businesses that see
patients and consult with local communities, corporations, and local government.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

Average Age
51 Only 20% of the PMH-RN

workforce are in their 20s or 30s

Profile:
THE PSYCHIATRIC-MENTAL HEALTH
REGISTERED NURSE

87+13
87%

Female

27% identify as a
racial or ethnic minority.

77%
Caucasian

PMH-RNs work within
the same scope of

practice regulations
across all U.S. states.

PMH-RNs make up the largest professional workforce in inpatient psychiatry, with more than 109,000 active in
the field today. The findings of the APNA workforce survey offer a useful snapshot of today’s PMH-RN.

The majority of PMH-RNs (61-71%)
report that for most patients they:

Assess physical health status

Assess mental health status

Educate patients and families

Approximately 40% of PMH-RNs
report they are providing counseling
and therapeutic relationships to most
patients, a key component historically
of the PMH-RN role.

80% of PMH-RNs in their 20s and
57% of PMH-RNs in their 30s have
earned a Bachelor of Science in
Nursing (BSN)

of PMH-RNs are currently enrolled
in a formal education program.25%

report earning a salary in the range
of $50,000-$99,00065%
report they provide telehealth services
and three-quarters of those report
providing telehealth services to patients
in rural areas.

41%

$

52+48
52.2%

staff
nurses

13+87
13.1%
nurse

educators

9+91
8.9%
nurse

managers

7+93
7.3%
nurse

administrators

6+94
6.4%

nursing
supervisors

PMH-RN Roles

89% work in hospitals

9+91

89+11
22+78 22.4% work in a mental health clinic

9.4% work for the Veterans Health Administration

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

PMH-RN FINDINGS OF NOTE:

• The PMH-RN workforce is aging; young professionals are needed to join the profession.
Nearly half of PMH-RNs report a plan to retire over the next 10 years, with an additional 13%
reporting they are undecided. We must attract many more people to pursue a career in PMH
nursing. Currently, the 20-29 age range makes up the smallest percentage of PMH nurses.

• The PMH-RN workforce has become increasingly well-educated. 82% of PMH-RN
respondents ages 20-29 indicate their initial nursing degree is a BSN – which is a higher level
of education than in the general RN population.

• PMH nursing is a great career opportunity for racial/ethnic and gender minorities in the
field. The PMH-RN workforce has a different racial/ethnic and gender composition than the
general RN population, with double the number of Black or African American nurses and a
greater proportion of multiracial nurses and male nurses among the PMH-RN population.

• Few PMH-RNs work in rural locations, which contributes to the service gap and challenges
with access in these areas of the country. PMH-RN respondents overwhelmingly work in
metropolitan counties. Of the 2,069 responding PMH-RNs, only 12 report working in rural
counties.

• PMH-RNs work in settings that accept a diverse payment mix. Because PMH-RNs
predominantly provide care within hospital and clinic settings, their care is often covered by
Medicare, Medicaid, and private insurance – unlike many other mental health care providers.

PMH-RNs have the potential to significantly transform the delivery of mental health and substance
use care. We must therefore advance efforts to attract more young professionals to careers in
PMH nursing across all areas of the U.S., with particular effort to expanding the numbers of those
working in non-hospital-based settings and underserved and rural areas.

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Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

Profile:
THE PSYCHIATRIC-MENTAL HEALTH
ADVANCED PRACTICE REGISTERED NURSE

70% practice in outpatient settings

2+98

70+30
15+85 15% practice in hospitals

2% practice in correctional facilities

PMH-APRNs…

Prescribe medications (76.3%)

Conduct diagnostic evaluations (66%)

Order lab tests and diagnostic studies (41.5%)

Provide education (81.5%)

Provide care coordination (43.5%)

Average Age
54 Just 25% of the PMH-APRN

population is under age 45

20% identify as a racial
or ethnic minority.

80%
Caucasian

90%
Female

PMH-APRNs possess additional education and training that qualifies them for advanced practice certification and
licensure. Recognized as one of the fastest growing Nurse Practitioner (NP) fields in the U.S., currently more than
39,000 PMH-APRNs provide mental health and substance use services in a wide variety of settings. Based on data
from the APNA PMH nursing workforce survey, here is a view of today’s PMH-APRN.

work in metropolitan ar-
eas of the country. Just
1% work in rural areas.

88%

47% of PMH-APRNs earn $100,000-150,000/yr
13% earn $75,000-99,000
11% earn $150,000-200,000$

70% of PMH-APRNs provide psychotherapy in
combination with medication management.

42% of PMH-APRNs completed Medication for
Addiction Treatment (MAT) waiver training to pro-
vide buprenorphine for opioid use disorders.
72% of those went on to apply for a DEA X-waiver.

88% of PMH-APRNs report having prescriptive
authority.

36% completed their PMH-APRN
preparation during the last decade.
DOUBLE the previous decade.

provide telehealth services.
On average, providing tele-
health services in 2 states
to 25 patients per week as
part of their practice.

85%

70+30
17+83
68+32

82% earned a Master of Science
in Nursing (MSN) degree.

17% earned a doctoral degree.

68.5% have graduated since 2000.

ANCC certification
among PMH-APRNs. 2013
(13,393 PMH-APRNs) to
2020 (26,690 PMH-APRNs)

2X
MORE

15

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

PMH-APRN FINDINGS OF NOTE:

• PMH nursing is one of the fastest growing fields among new nurse practitioners. PMH-
NP programs have nearly doubled over the past 8 years (114 programs in 2015, 208 programs
in 2021). In addition, PMH-NP lifespan certifications have increased 30% since 2019. Continu-
ing this expansion of preparation for and practicing PMH-APRNs is critical to addressing the
nation’s shortage of psychiatric-mental health professionals.

• PMH-APRNs provide two key primary mental health functions. 70% of PMH-APRNs
provide psychotherapy in combination with medication management.

• PMH-APRNs increase equity and access to mental health and substance use disorder
services. Nearly 70% of PMH-APRNs indicated that most of their patients use insurance.
Providing services to this patient population is critical as an estimated 45% of psychiatrists
and 30% of psychologists do not accept any form of insurance.

• Most PMH-APRNs expand access to mental health and substance use disorder care by
providing telehealth services. It’s important to note that since the APNA study was con-
ducted at the beginning of the COVID-19 pandemic, the telehealth data may represent only a
fraction of those services, as PMH-APRN regulations and ability greatly expanded during the
last 2 years. (Some states only temporarily enabled PMH-APRNs to provide these services
during the Public Health Emergency.) Future research and policies will continue to look at
expanding the availability of telehealth services.

• PMH-APRNs are one of just three other professions licensed to provide the full range of
mental health services, including prescribing medications in most states. As the number
of practicing PMH-APRNs expand, the current lack of hospital admitting privileges may
become a significant barrier to patients in acute distress who need access to mental health
services.

• PMH-APRNs are a vital resource for closing disparities in opioid treatment. A significant
and growing percentage of recent PMH-APRN graduates have gone on to complete Medi-
cation for Addiction Treatment (MAT) training, which allows them to obtain a DEA X-waiver to
prescribe buprenorphine for opioid use disorders.

PMH-APRN Workforce
Numbers by Certification

2004 2006 2008 2010 2012 2016 2018 2020 2022
0

15,000

30,000
NP
CNS

Total

26,680

22,023

4,657

16

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

OBSTACLES TO EXPANDING PMH NURSING
TO IMPROVE ACCESS & EQUITY IN
MENTAL HEALTH CARE
More PMH nurses are needed to address the nation’s shortage of qualified psychiatric-mental health
professionals.

Interestingly, the importance of the growth in PMH-APRNs was recently documented in a new study
led by researchers at the Harvard T.H. Chan School of Public Health, which found that the number of
PMH-NPs increased 162% from 2011-2019 – to providing nearly 1 in every 3 mental health prescriber
visits to Medicare patients nationally in 2019 – while the number of psychiatrists billing Medicare
dropped by 6% during that period. The study determined that without this growth in the PMH-NP
workforce, there would have been a steep 30% decline in mental health specialist visits for
Medicare patients. Instead, the drop was just 12%.

These findings put a direct spotlight on the vital role PMH nurses play within the mental health
workforce and illustrate the positive impact these professionals can make in helping to address the
ongoing mental health crisis.

While PMH nursing is a rapidly expanding profession with strong career trajectories and compensa-
tion, nursing educators, policymakers, state regulators, and those within the profession must
come together to find ways to attract, mentor, and empower more PMH nursing professionals
to increase access to mental health care.

To accomplish this, two key ongoing challenges

must be addressed:

1) Nursing Education has not kept pace with the demand for PMH nurses.

While there has been strong expansion of PMH-NP programs to help grow the next
generation of PMH-APRN practitioners, very few undergraduate nursing schools
are able to offer students exposure to PMH nursing-specific education delivered
by an expert in the field; PMH nursing mentors; or opportunities to learn about the
profession.

Students enrolled in general nursing programs continue to report an overall lack
of defined, testable mental health care content and competencies included within
current nursing school curriculum. This ongoing shortage of PMH nursing faculty at
the undergraduate and graduate levels blocks the development of a pipeline of PMH
nurses needed to expand the workforce.

17

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

In addition, when surveyed by APNA, PMH-RNs report that one of the barriers they
encounter in pursuing a career in PMH nursing was nursing school faculty members
misrepresenting the experience required prior to becoming a PMH-RN. These
findings are consistent with research that suggests there is a stigma associated
with specializing in PMH nursing and a negative view of PMH nursing persisting
within nursing schools.

2) Many States Still Unnecessarily Restrict the Scope of Practice of PMH Nurses

Currently, 26 states and the District of Colum-
bia fully allow PMH-APRNs to diagnose, treat,
order diagnostic tests, and prescribe medica-
tions to patients without physician oversight.

Despite the rapidly expanding mental health
crisis, 13 states continue to limit PMH-APRN
scope and practice and an additional 11 states’
regulations severely restrict PMH nursing scope
of practice.

PMH nurses must be permitted to work to the
full extent and authority of their education
and training.

If the goal is increasing patient access to quality
mental health and substance use care, the
important role of PMH nurses must be fully
employed in both education and in practice.

Full Practice

Reduced Practice

Restricted Practice

Map Source: AANP

Eliminating restrictions on the
scope of practice of advanced
practice registered nurses and
registered nurses so they can
practice to the full extent of
their education and training will
increase the types and amount of
high-quality health care services
that can be provided to those
with complex health and social
needs and improve both access
to care and health equity”

— National Academies of
Sciences, Engineering & Med-
icine The Future of Nursing 2020-
2030: Charting a Path to Achieve
Health Equity

18

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

A Call to Action
TO ADDRESS THE MENTAL HEALTH
STATE OF EMERGENCY

PMH nurses play a pivotal and expanding role within the U.S.
mental health workforce. In addition to consistently holding the
top position of public trust within the field of health care, nurses
working in psychiatric-mental health are rigorously educated,
clinically trained, and provide a wide range of evidence-based care
and treatment.

PMH nurses actively expand access and health equity by working
in a wide variety of care settings, accepting most forms of govern-
ment and private insurance, and leveraging telehealth services to
reach patients in underserved areas.

The nation needs more PMH nurses to reduce the shortage of accessible mental health professionals
and expand health equity across under-resourced communities.

As mentioned previously, SAMHSA called for more than half a million additional PMH nurses to reach
“merely adequate access” to mental health and substance use care. To create a trajectory towards
addressing the shortage of qualified mental health professionals, key national stakeholders
and policymakers must consider the following opportunities:

• The deep skillsets and vital role of PMH nurses must be fully understood by policymakers,
government regulators, and industry influencers so the number and roles of PMH nurses
can be intentionally expanded in light of the widespread shortage of mental health providers
and the high rate of retirements forecasted among practicing mental health professionals.

• Leaders at top health and mental health organizations should include the full picture of
the PMH nursing workforce in discussions about the nation’s mental health workforce
and leverage PMH nurse expertise in efforts to design solutions to our nation’s pressing
mental health challenges.

• Mental health stakeholders should use data from the APNA workforce report to inform
studies and decisions about the mental health workforce and access to funding.
Comprehensive information about PMH nurses and their skillsets must be included in these
national-level discussions about mental health treatment, access, and health equity.

SAMHSA reports the need
for more than half a million
additional Psychiatric-Mental
Health (PMH) nurses to reach
merely adequate access to
mental health and substance
use care.

!

19

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

• Policymakers in states that currently limit PMH nurses’ scope of practice should be
better informed about the full range of services in which PMH nurses are educated and
trained, and their potential to broaden access to mental health and substance use care.
PMH nurses must be utilized to the full extent and authority of their education and training
within health care systems across ALL states.

• Schools of Nursing can embrace their role in helping to solve the psychiatric-mental
health provider shortage by recruiting and educating more PMH nurses. Nursing edu-
cation institutions can ensure that their curriculum promotes an understanding that mental
health and substance use disorders should not be stigmatized – they are illnesses from which
recovery is possible. Nursing schools can broaden students’ access to PMH nursing-specific
education; provide information about careers in PMH nursing; recruit more PMH nursing
faculty; offer students psychiatric rotations in a variety of settings; and connect students with
experienced PMH nurses.

• All stakeholders in mental health care must recognize and prioritize the need to recruit
and train a more diverse PMH nursing workforce, as PMH nurses are uniquely equipped
to advance health equity across circumstances, communities, and abilities. Strengthening
the number of PMH nurses will further align public health, health care, and social services to
eliminate health disparities and achieve health equity in all communities.

• Solutions must be developed to help attract more PMH nurses to work in and expand
the reach into rural and underserved areas of the country. The previously mentioned
Harvard study found that in states where PMHNPs have no restrictions on prescribing
medication, they account for 50% of the mental health prescriber visits in rural areas. To
further bolster the reach of mental health care in rural areas, we must increase awareness,
availability, and the effectiveness of telemental health services there. Currently, telehealth
services are out of reach for 21 million Americans who still do not have access to broadband
Internet in their communities.

• U.S. health care stakeholders must prioritize the integration of substance use and
mental health screening within primary health care visits nationally to educate patients
and effectively guide them to treatment resources. In addition, increased resources and
funding for substance use treatment both long and short term, including tobacco use are
needed to more effectively address the nation’s rising rates of substance use disorders.

• Ongoing research is needed to study the impact and growth of the PMH nursing work-
force to adequately represent this field to government decision-makers and stakeholders.

20

Psychiatric-Mental Health Nurses Are Key to Addressing the Nation’s Mental Health Crisis www.APNA.org

CONCLUSION

An expanded workforce of highly skilled PMH nurses has the potential to meet gaps in access and
equity within mental health and substance use care throughout the nation.

Therefore, it is vital that national-level mental health stakeholders fully understand the important im-
pact and contributions of the PMH nursing workforce; support efforts to allow PMH nurses to practice
to the full extent of their education and training in all states; and help attract young professionals from
diverse backgrounds to pursue careers in PMH nursing.

PMH nurses have been the unrecognized solution in most national-level discussions of access and
equity within mental health and substance use care. As a result, this comprehensive PMH nursing
workforce report aims to fuel national stakeholder understanding and help identify key trends to
inform future policy and funding decisions impacting mental health care.

APNA is committed to advancing PMH nursing and has stepped forward to provide research, educa-
tion, and resources to continually strengthen the skillsets of PMH nurses.

For example, APNA provides:

• 24 hours of MAT education
• Access to free undergraduate faculty resources
• Expanded suicide prevention education
• Free opioid education and resources
• Curriculum to help nurses transition into the psychiatric-mental health field

APNA is also working to inspire nursing students to pursue careers in PMH nursing by:
• Encouraging increased student exposure to PMH nursing
• Providing annual student scholarships,
• Facilitating avenues for students to connect with career mentors
• Offering discounted student memberships with numerous benefits

Through this ongoing workforce development initiative, APNA continues to communicate essential
data and information to decision-makers and stakeholders to ensure that, as policies and systems are
constructed to expand access to mental health care, psychiatric-mental health nurses are utilized to
the full scope of their roles.

The core of any national effort to address the shortage of mental health professionals and
reduce the number of Americans in need of treatment must be an expansion of the PMH
nursing workforce to practice within the full scope and authority of their education and training
in all states.

APNA looks forward to contributing vital PMH workforce data to the national conversation and part-
nering with key mental health stakeholder organizations to address shared goals of improved access
and equity in mental health care.

21

APNA 2022
PSYCHIATRIC-MENTAL HEALTH NURSING

WORKFORCE
REPORT

www.APNA.org

The First Study Specifically Targeting the

Psychiatric-Mental Health Nursing Workforce

2Acknowledgements | APNA 2022 PMH NURSING WORKFORCE REPORT

ACKNOWLEDGMENTS

The American Psychiatric Nurses Association Board of Directors would like to thank
the APNA Workforce Task Force for developing the APNA Psychiatric-Mental Health

Nursing Workforce Survey, analyzing data, and preparing this report.

APNA Workforce Task Force: Angela M. Gerolamo, PhD, CRNP, PMHNP-BC (Chair);
Kathleen R. Delaney, PhD, PMHNP-BC, FAAN; Bethany Phoenix, PhD, RN, FAAN; Amy
Rushton, DNP, PMHCNS-BC; Janette Stallings, MA, MSN, APRN, PMHNP, BC; Patricia

Black, PhD, RN, FAAN (APNA Staff)

The task force would like to thank Dawn Vanderhoef for her leadership and assistance
with survey development, the APNA Board of Directors Student Scholars (Whitney D.

Bagby, Brook Alicia Condrey, Geo Guerrero, Tashae Gomez Jones, Bethany Mandy,
Sarah O’Neil and Alexandra Taylor) for assistance with data analysis, and Hugh

Vondracek for statistical analysis support. Finally, the authors would like to express
gratitude to the PMH-RNs and PMH-APRNs who participated in the surveys.

3tAble of contents | APNA 2022 PMH NURSING WORKFORCE REPORT

Key Findings of the 2022 APNA Psychiatric-Mental Health Nursing Workforce Survey ……………………4

Survey Methodology ………………………………………………………………………………………………………………………………..6

Psychiatric-Mental Health Registered Nurse (PMH-RN) Survey Findings …………………………………………7
Executive Summary ……………………………………………………………………………………………………………….7
Demographics ………………………………………………………………………………………………………………………..8
Human Capital ………………………………………………………………………………………………………………………..12
Employment ……………………………………………………………………………………………………………………………13
Earnings …………………………………………………………………………………………………………………………………..16
Discussion ………………………………………………………………………………………………………………………………17

Psychiatric-Mental Health Advanced Practice Registered Nurse (PMH-APRN) Survey Findings ……20
Executive Summary ……………………………………………………………………………………………………………….20
Demographics ………………………………………………………………………………………………………………………..21
Human Capital ………………………………………………………………………………………………………………………..23
Employment ……………………………………………………………………………………………………………………………26
Earnings …………………………………………………………………………………………………………………………………..31
Discussion ………………………………………………………………………………………………………………………………32

Report Summary ………………………………………………………………………………………………………………………………………35

References ………………………………………………………………………………………………………………………………………………..37

TABLE OF CONTENTS

4key findings | APNA 2022 PMH NURSING WORKFORCE REPORT

KEY FINDINGS

Key Findings of the 2022 APNA Psychiatric-Mental Health
Nursing Workforce Survey

PSYCHIATRIC-MENTAL HEALTH REGISTERED NURSES (PMH-RNs):

• Among all age groups of PMH-RNs, the 20-29 age range comprises the
smallest percentage of nurses.

• The PMH-RN workforce has a different racial/ethnic and gender
composition than the general RN population, with double the number of
Black or African American nurses and a greater proportion of multiracial
nurses and males in the PMH-RN population.

• About half of the sample reported a Bachelor of Science in Nursing (BSN)
as their highest degree, and 82% of respondents ages 20-29 indicated their
initial degree is a BSN

• The hospital is the primary employment setting for a majority (62%) of
PMH-RNs.

• The majority of respondents (61-71%) reported that they assess physical
health status, assess mental health status, and educate patients and
families for most patients. About 40% of PMH-RNs reported that they are
providing counseling and developing therapeutic relationships to most
patients, which has historically been a key component of the PMH-RN role.

• Less than two-thirds of respondents reported feeling either safe or very
safe in their work settings. Patient acuity (59%), level of administrative
support (56%), staffing ratio (55%), and level of staff training (54%) were
cited by a majority of respondents as factors that influenced their feelings
of workplace safety.

• Pre-tax annual income from primary employment was in the $50,000-
99,000 range for 65% of respondents.

5key findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PSYCHIATRIC-MENTAL HEALTH ADVANCED PRACTICE
REGISTERED NURSES (PMH-APRNs):

• The average age of PMH-APRNs is 54 years, with more than half of the
respondents in their 50s or 60s.

• 27% of respondents plan on retiring in the next six years, with a greater
percent of intended retirements among Clinical Nurse Specialists.

• Although the majority of PMH-APRNs identify as white (84%), the
proportion of respondents that identified as Black or African American
in the PMH-APRN sample is slightly larger (10%) than the broader NP
population, but lower (3%) in terms of PMH-APRNs who identify as Latinx.

• More than two-thirds of respondents reported a Master of Science (MSN)
as their highest degree, and their initial PMH-APRN preparation.

• Most respondents (70%) practice in outpatient settings that include mental
health clinics, community-based programs, federally qualified healthcare
centers (FQHCs), and community health centers.

• Approximately 42% of respondents completed Medication for Addiction
Treatment (MAT) training and 72% of these subsequently applied for
a U.S. Drug Enforcement Administration (DEA) X-waiver to prescribe
Buprenorphine for opioid use disorders.

• A majority of respondents treat patients who hold commercial insurance
or Medicaid/Medicare, with close to half stating most of their clients were
covered by federal insurance.

• Pre-tax annual income from primary employment was in the $100,000-
150,000 range for 47% of respondents.

6methodology | APNA 2022 PMH NURSING WORKFORCE REPORT

METHODOLOGY

Workforce Survey Methodology

The American Psychiatric Nurses Association (APNA) convened a Workforce Task Force
comprised of six members to develop a comprehensive survey of the Psychiatric-Mental
Health (PMH) Nursing workforce. The goal of the survey is to understand the demographic,
education, employment characteristics, and earnings of PMH nurses working throughout the
United States. The primary data source for this report was from a voluntary survey offered to
contacts in APNA’s database, registered nurses, and advanced practice nurses with current
certification by the American Nurses Credentialing Center (ANCC).

The Workforce Task Force began survey development on September 7, 2018. Separate
surveys were developed for Psychiatric-Mental Health Registered Nurses (PMH-RNs) and
Psychiatric-Mental Health Advanced Practice Registered Nurses (PMH-APRNs) to reflect
the unique scope of each role. To inform survey development, the Task Force examined the
following sources: American Psychological Association 2015 survey; APNA minimum data
set (MDS); Health Resources and Services Administration National Sample Survey of Nurse
Practitioners; National Workforce Survey of RNs; Nursing Minimum Data Set; Minimum Data
Set for the Behavioral Health Workforce developed by the University of Michigan; and the
American Psychiatric Association Draft Workforce Survey. This approach ensured a systematic
and comprehensive examination of the types of data that other behavioral health disciplines
collect. Both surveys were reviewed by a researcher with content and methodological
expertise in workforce research. Each survey was pilot tested with 100 individuals. Survey
items were revised to improve readability and clarity. Each survey included a glossary of terms
to ensure consistent interpretation among participants.

The PMH-RN survey included 51 questions and the PMH-APRN survey included 52 questions.
Surveys were administered from October 21, 2020 to February 24, 2021. The PMH-RN survey
was completed by 4,088 PMH-RNs and the PMH-APRN survey was completed by 5,158 PMH-
APRNs. The combined response rate for the surveys is 12.1%. Statistical Package for the Social
Sciences (SPSS) was used for data management and analysis. Frequencies, percentages, and
cross tabulations were used to summarize the data. A consultant was engaged to assist with
statistical analysis.

The findings should be considered in light of the study limitations. First, the sample is
comprised of PMH-RNs and PMH-APRNs who are contacts in the APNA database and/or
certified by ANCC who may not be representative of the full Psychiatric-Mental Health Nursing
workforce. Second, the response rate is low suggesting potential nonresponse bias. Finally,
the survey was administered during the COVID-19 pandemic when social distancing and other
restrictions were in place which could have influenced the findings. Despite these limitations,
this is the first research study that specifically targets the PMH nursing workforce.

7Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PMH-RN SURVEY FINDINGS

Psychiatric-Mental Health Registered Nurse
Survey Findings

EXECUTIVE SUMMARY

Data on the characteristics and supply of Psychiatric-Mental Health (PMH) Registered Nurses
(RNs) and Advanced Practice Registered Nurses (APRNs) are essential to expanding access
to behavioral health care and informing workforce projections. The first section of this report
contains data on the demographics of the current PMH-RN workforce and their educational
preparation, employment characteristics, and earnings.

The PMH-RN workforce is aging similarly to the nurse population as a whole. The average age
of PMH-RNs is 51 years, with more than half of the respondents in their 50s or 60s. Only 4% of
PMH-RNs are in the 20-29 age range. The top two reasons respondents reported as barriers
to becoming a PMH-RN are (1) individuals felt they needed medical-surgical experience and,
(2) a faculty member told them they needed medical-surgical experience prior to becoming a
PMH-RN.

Although the majority (77%) of PMH-RNs are White, the proportion of respondents that
identified as Black or African American (13%) in the PMH-RN sample is double that of the
national RN sample. Further, a greater proportion of PMH-RNs identified as Multiracial (4%)
compared with the national RN sample. Finally, males comprise a greater proportion (12%)
of the PMH-RN population compared with their male counterparts in the general nursing
population.

About half of the sample reported a Bachelor of Science in Nursing (BSN) as their highest
degree, and 82% of respondents ages 20-29 indicated their initial degree is a BSN. Rates of
certification vary by race and age with the highest proportion of certified nurses identifying as
older and White. Nurses who are certified in a specialized area of nursing are recognized as
having advanced knowledge, skills, and expertise. PMH-RNs noted that the top reason for not
obtaining certification is because it is not valued by their employer.

Compared with a national sample of RNs, more PMH-RNs (89%) reported a hospital as their
primary employment setting. Further, the majority of respondents (between 61 and 71%)
reported that they assess physical health status, assess mental health status, and educate

overview

demographics

education

employment
characteristics

8Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

patients and families for most patients. However, approximately 60% reported that they are
not providing counseling and developing a therapeutic relationship with most patients, which
has historically been a key component of the PMH-RN role.

Pre-tax annual income from primary employment was in the $50,000-99,000 range for about
two-thirds of respondents. Income from primary employment tended to increase with age
up to 70 years and then decreased. Nurse administrators most frequently reported earning
greater than $100,000, followed by nurse managers and those working in correctional facilities.
PMH-RN respondents who reported earning less than $75,000 disproportionately identified
as American Indian and Alaskan Native and PMH-RNs employed in rural counties. PMH-RN
respondents who reported earning less than $50,000 more often reported working in school-
based clinics and in home psychiatric care.

FULL DATA FROM THE APNA PMH-RN SURVEY

APNA survey findings are compared with data from the 2020 National Workforce Survey which reflects a nationally
representative sample. This survey is produced by the National Council of State Boards of Nursing (NCSBN) in
partnership with the National Forum of State Nursing Workforce Centers.

DEMOGRAPHICS

The average age of the 3,494 PMH-RN survey participants is 51 years (SD=12.5; median=52),
ranging from 22 to 101 years old. The average age of PMH-RN survey respondents is consistent
with the average age of RNs reported nationally, which is 52 years old (NCSBN, 2020). More
than half of the respondents (53%) are in their 50s or 60s. In a national sample of RNs, 8%
of nurses are between the ages of 20-29 (NCSBN, 2020) while only 4% of PMH-RNs in our
sample are in that age range. (Figure 1 presents the age distribution of participants by selected
decades.) Age is calculated by participant responses to date of birth. The large proportion of
PMH-RNs in their 50s and 60s represents a significant context for many other observations in
this report.

earnings

Age

20-29

25%

0%
30-39 40-49 50-59 60-69 70-79 80-89 100+

Age of the workforce
Figure 1

Age by Decade

%
o

f R
es

po
nd

en
ts

9Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 3,491 PMH-RNs, 87% reported their gender as female, 12% reported male gender, and
0.4% reported either non-binary or transgender. Similarly, 87% were assigned female on
their original birth certificate while 12% were assigned male. The percentage of respondents
reporting male gender is slightly higher than the 9% of RNs reporting male gender in a
nationally representative sample (NCSBN, 2020). Of the PMH-RNs that responded, 8%
identify as sexual minorities such as gay, lesbian, and bisexual.

Of 3,462 PMH-RNs responding, more than three-quarters (77%) identified as White (See Table
1). About one quarter of respondents identified as racial or ethnic minorities, and 4% identify as
multiracial. Similarly, in a national sample, almost 81% of RNs identified as White. However, the
second most frequently identified race among the national sample was Asian (7%) (NCSBN,
2020), compared with 6% of respondents in the PMH-RN sample identifying as Asian. In the
PMH-RN sample, the second most frequently identified race was Black or African American
(13%) compared with only 6% of RNs in the national sample (NCSBN, 2020).

The United States Census Data show that 18% of the population identifies as Hispanic and
any race. The Census Data measures ethnicity and race separately through two items while
our survey asked respondents to identify their race with Latinx as one of the options. Only 4%
of respondents identified as Latinx suggesting a significant underrepresentation of this ethnic
subgroup compared with the general population. (See Figure 2 for racial distribution among
the sample of PMH-RNs.) Almost 4% of PMH-RNs identified as multiracial compared with 2%
of RNs in a national sample reporting two or more races (NCSBN, 2020) and about 3% of the
population reporting two or more races in the 2019 United States Census Data.

Of 3,386 responding PMH-RNs, almost one quarter speak at least one language in addition to
English; 3% speak two or more languages in addition to English. The most common language
spoken in addition to English is Spanish which was reported by 11% of RNs.

gender, sex,
and sexual
orientation

Race/ethnicity

Table 1: Race/ethnicity

White 77.2%

Black or African American 13.2%

Asian 6.4%

Latinx 4.5%

American Indian or Alaska Native 1.8%

Native Hawaiian or Pacific Islander 0.7%

Prefer not to answer 0.5%

RN Racial Distribution

White Black or African American

Asian Latin-x

American Indian or Alaska Native Native Hawai ian or Pacific Islander

Prefer not to answer

Pmh-Rn Racial distribution
Figure 2

10Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PMH-RNs that identify as White are likely to be older, on average, than any other racial group.
This is consistent with general demographic trends in the US population. (See Table 2)

Figure 3 shows the race/ethnicity distribution across age groups. Race/ethnicity categories
are not mutually exclusive.

Race/ethnicity
by Age

Table 2

ethnicity n Age m (sd) min max

White 77.2% 52.17 (12.59) 22 101

Black or African American 13.2% 50.72 (11.68) 25 79

Asian 6.4% 45.75 (11.38) 24 81

Latinx 4.5% 46.31 (11.89) 25 75

American Indian or Alaska Native 1.8% 47.31 (10.85) 25 65

Native Hawaiian or Pacific Islander 0.7% 44.63 (10.31) 27 63

*scale approximate

100%

75%

50%

25%

0%

Race/ethnicity by Age*
Figure 3

OVERALL
(n=3494)

White
(n=2671)

Black or
African

American
(n=456)

Asian
(n=222)

Latinx
(n=155)

American
Indian or
Alaskan
Native
(n=64)

Native
Hawaiian
or Pacific
Islander
(n=24)

Prefer not to
answer
(n=15)

20-29 30-39 40-49 50-59 60-69 70-79 80-89 100+

11Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Race/ethnicity does not significantly vary by gender among responding PMH-RNs. (Table 3
shows the number of respondents that comprise each racial category by reported gender.)

Of 3,476 PMH-RNs, 6% are veterans, 0.5% are on active duty, and 2% are in the reserves or
National Guard. PMH-RNs in their 70s have the highest (9%) proportion of veterans, and those
in their 20s have the lowest proportion of veterans (2%).

Race/ethnicity
by gender

Active duty
service

table 3

gender overall Race

n %

American
Indian or
Alaska
Native

Asian
Black or
African
American

Native
Hawaiian
or Pacific
Islander

White Latinx

Female 3,009 87.2% 55 177 392 21 2,334 126

Male 426 12.4% 8 41 56 3 304 27

Non-Binary 13 0.3% 0 0 1 0 12 0

Transgender 2 0.1% 0 0 0 0 2 0

total 3,449 100% 63 222 451 24 2,668 155

12Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

HUMAN CAPITAL

Forty-five percent of respondents qualified for their initial RN license by obtaining an Associate
Degree in Nursing, while 42% earned a Bachelor of Science in Nursing (BSN) as their first
nursing degree. Eighty-two percent of PMH-RNs in their 20s and 57% of PMH-RNs in their
30s first qualified for their initial RN license by earning a BSN. This trend holds across gender.
Similarly, 42% of RNs in a national sample qualified for their first RN license by earning a BSN
degree, a trend that has increased over the past several years (NCSBN, 2020). Respondents
who identified as Asian (66%) and Native Hawaiian and Pacific Islanders (50%) were the only
racial groups where a majority obtained a BSN degree to qualify for their first RN license.

3,948 PMH-RNs reported that on average, 8% of their didactic coursework for their initial RN
education was completed online (SD=18.1). Two-thirds of PMH-RN respondents reported that
none of their coursework was online.

Half of responding PMH-RNs reported their highest degree as a Bachelor of Science in
Nursing (BSN) which is consistent with the NCSBN (2020) survey that showing that 48%
of RNs reported their highest degree as a Bachelor of Science in Nursing. There are no
differences in highest degree earned by race or certification. Black or African American PMH-
RNs have the highest proportion (38%) of MSN training. The proportion of PMH-RNs who hold
a BSN tends to decrease with age, with PMH-RNs more likely to have either an Associate’s or
Master’s degree with each successive decade.

Of 3,987 PMH-RN respondents, 15% reported that they completed a new graduate residency
or fellowship program. These PMH-RNs reported that their new graduate residency or
fellowship program lasted an average of 8.4 months (SD=5.8) ranging from 0 to 36 months.
More than half of PMH-RN respondents to this question reported their residency or fellowship
program was less than one year. About three quarters of PMH-RN respondents who
completed a new graduate residency or fellowship program reported that they were either
satisfied or very satisfied with the program. There were no differences in program satisfaction
by age, gender, or Magnet hospital status.

One quarter of PMH-RN respondents reported current enrollment in a formal education
program. More than half of all Black or African American PMH-RN respondents reported
current enrollment in a formal education program while White PMH-RN respondents were the
least likely to be enrolled in an education program. Slightly more men (30%) were enrolled

education

Percentage of
coursework
online for
initial Rn
education

highest
degree earned

new graduate
Residency or
fellowship
Program

current
enrollment
in nursing
Program

13Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

than women (25%), and PMH-RNs in their 20s (48%) and 30s (42%) were the age groups most
likely to report enrollment in a formal education program.

Respondents were licensed in all 50 states, as well as Washington, DC, with 76% of
respondents licensed in one state, and 20% licensed in 2 to 4 states. Almost half of responding
PMH-RNs reported holding an American Nurses Credentialing Center (ANCC) certification as
a PMH-RN. Rates of certification by race include 47% of all White PMH-RNs being certified,
45% of Asian PMH-RNs, 43% of Latinx PMH-RNs, 42% of Black or African American PMH-RNs,
42% of Native Hawaiian or Pacific Islander PMH-RNs, and 28% of American Indian or Alaska
Native PMH-RNs being certified. Although there is no substantive difference between the
proportion of certification among men and women, the proportion of PMH-RNs holding an
ANCC certification increases with age. In addition, rates of ANCC certification vary by primary
role in employment setting, ranging from 64% of utilization review nurses to 43% of nurse
educators. The two most common reasons reported for not being certified by ANCC are cost
and that certification is not valued by current employer.

About half of PMH-RN respondents plan to retire more than 10 years from now with 13%
undecided. Unsurprisingly, older PMH-RNs in more senior roles tend to anticipate retiring
sooner than their younger or more junior counterparts. There were no differences in
characteristics among respondents who were undecided about retirement.

EMPLOYMENT CHARACTERISTICS

The average number of years of experience among respondents is 6.6 (SD=8.7) with a median
of three years of RN experience prior to becoming a PMH-RN. Twenty-nine percent of
those respondents did not have any prior nursing experience, and 10% had only one year of
experience prior to becoming a PMH-RN. Older nurses tend to have more nursing experience
prior to becoming a PMH-RN. However, years of experience as an RN prior to becoming a
PMH-RN does not vary by type of role. While more than half of respondents did not experience
barriers to becoming a PMH-RN, the most common barriers reported by those who reported
barriers are, ‘I felt I needed general/medical nursing experience before entering PMH
nursing’, and ‘faculty advised me that I needed medical-surgical experience before going into
psychiatric-mental health.’ Females and younger RN respondents were more likely to feel that
they needed more nursing experience before becoming a PMH-RN.

Of 3,787 responding PMH-RNs, 52% are staff nurses, 13% are nurse educators, 9% are nurse
managers, 7% are nurse administrators, and 6% are nursing supervisors. The remainder of
respondents selected ‘other’ noting roles such as care/case manager, utilization review nurse,
consultant, and retired. The proportion of respondents working in staff nurse roles decreases
with age and with years of experience.

state
licensure and
certification

Plans for
Retirement

experience
as a
Psychiatric-
mental health
nurse

Pmh-Rn Roles

14Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 2,069 responding PMH-RNs, only 12 work in rural counties. PMH-RN respondents
overwhelmingly work in metropolitan counties. 2,214 PMH-RNs reported living an average of
14.56 miles (SD=11.76; median=11.2; range: 0.5-91) from their primary employment.

Of 3,756 responding PMH-RNs, 62% work in a hospital setting, 14% in an ambulatory care/
outpatient setting and 7% in an education/academic setting. The percentage of PMH-RNs
working in a hospital as their primary employment setting is higher than that reported by a
national sample of RNs which is 55%. (NCSBN, 2020). The proportion of PMH-RNs working
in hospital settings decreases with age. Other settings less frequently reported by PMH-RN
respondents include: residential/long-term care, psychiatric home care, college/university
counseling center, school-based clinic, correctional facility, private practice/consulting, health
plan/insurance, and retired or unemployed.

Of PMH-RN respondents who reported working in a
non-hospital setting, 22% reported working in a mental
health clinic and 9% reported working for the Veterans
Health Administration. Almost three-quarters of these
respondents reported completing an orientation for
their position, but only 10% completed a fellowship
or residency, and only 11% work at a Magnet certified
facility. The majority of respondents working in a non-
hospital setting are female and White. More than two-
thirds of PMH-RNs working in non-hospital settings are
age 50 or older. However, primary or specialist medical
care and community health center settings had more
than 30% of PMH-RNs under age 40. A BSN in nursing
degree is the most common maximum credential,
with the exception of PMH-APRN offices, academic
settings, and long-term care settings.

Of 3,394 responding PMH-RNs, 88% reported having completed an orientation for their
primary RN position. Of 2,995 responding PMH-RNs, 32% reported having an orientation that
lasted 10-19 days, with PMH-RNs working at ANCC Magnet certified facilities representing
the greatest proportion of PMH-RNs reporting an orientation of greater than one month.
Orientation length was longest in hospitals, ambulatory or outpatient settings, and
correctional facilities. As the length of orientation increased, the proportion of PMH-RNs either
satisfied or very satisfied with orientation increased from less than 25% for no orientation to
more than 75% for orientations lasting over one month. Orientations were least likely to be
offered in private practice or consulting. Overall, 63% of PMH-RNs were either satisfied or
very satisfied with their orientations, but of those working in Magnet certified facilities 71%
were either satisfied or very satisfied with their orientations. PMH-RNs in private practice or
consulting and hospital settings were most likely to be either satisfied or very satisfied with
their orientations, and those in correctional facilities were the least satisfied. Satisfaction with
orientation did not vary by age or gender.

Primary
employment
setting

Top Three Primary Employment Settings

Hospital Ambulatory/Outpatient Education/Academic

top 3 Pmh-Rn Primary
employment settings

Figure 4

Hospital
Ambulatory/Outpatient
Education/Academic

15Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 3,027 PMH-RNs, 64% reported that a preceptor was assigned to them during orientation.
Approximately two-thirds of PMH-RNs working at Magnet certified facilities and hospital
settings were assigned a preceptor during orientation. There is a relationship between the
presence of an orientation preceptor and PMH-RN satisfaction with orientation: of those
assigned a preceptor, 75% were satisfied or very satisfied, and only 8% were dissatisfied or
very dissatisfied.

Of the 43% of PMH-RNs who responded that they precept nursing students, the average
number of nursing students precepted is 10 per year ranging from 1-50. We speculate that
some respondents reported the number of nursing students in each clinical group as opposed
to one-to-one preceptorship, thereby inflating the mean. There are no differences in the
number of students precepted by level of education or experience of the PMH-RN preceptor.

Less than two-thirds of respondents reported feeling either safe or very safe on the job.
Perceptions of safety did not depend on whether respondents worked at a Magnet certified
facility, completed a residency or fellowship, held an ANCC certification, completed an
orientation program, or had a preceptor. Feelings of safety also did not vary by gender,
population served, length of orientation, or hours worked per week. Feelings of safety
increased with increased experience and levels of education. Feelings of safety also varied by
work environment, with PMH-RNs in academic or university and school-based clinic settings
feeling most safe, and PMH-RNs in correctional facilities and hospital settings feeling least
safe.

3,363 PMH-RNs identified factors that influenced their feelings of safety at the workplace.
Patient acuity (59%), level of administrative support (56%), staffing ratio (55%), and level of
staff training (54%) were cited by a majority of respondents as factors that influenced their
feelings of workplace safety. However, security was not identified as a factor in perceptions of
safety, particularly among PMH-RNs in their 30s. Patient acuity was the most cited factor for
PMH-RNs in their 20s, 30s, and 40s while level of administrative support the most cited factor
for PMH-RNs in their 50s, 60s, and 70s.

Adults are the primary population served by PMH-RN respondents across employment
settings, except for home psychiatric care and school-based clinic settings serving geriatric
and child/adolescent populations, respectively. PMH-RNs in private practice/consulting
settings are roughly evenly split between lifespan (45%) and geriatric (39%) populations. The
3,584 responding PMH-RNs reported that 46% (SD=25.0) of their patient population is, on
average, from a racial or ethnic minority. About two-thirds of responding PMH-RNs report that
up to 24% of their patient population has limited English proficiency.

Respondents described a range of services they provide in their primary employment setting
by indicating if they provide a particular service to no patients, few, some, or most patients.
Between 61 and 71% of respondents reported that they assess physical health status, assess
mental health status, and educate patients and families for most patients. About 40% of

Perception of
safety

Populations
served

services
Provided

16Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

respondents reported that they provide care coordination, therapeutic relationship and
counseling, crisis management, and milieu therapy to most patients. Approximately one-
quarter of respondents noted that they provide consult liaison, groups, and make referrals for
most patients.

Of 3,584 responding PMH-RNs, 41% reported that they provide telehealth services in any
of their employment settings. Three quarters of respondents reported that they provide
telehealth services in rural counties. About three-quarters (72%) of case or care managers
and ambulatory or outpatient PMH-RNs reported providing telehealth services. Of PMH-RN
respondents providing telehealth services, they reported providing telehealth to an average
of 14.3 and a median of 10 patients per week (SD=15) [range: 0-50]. Few respondents provide
telehealth services in more than one state.

Of 3,654 responding PMH-RNs, 19% reported holding a second nursing position, which is
greater than the percentage of RNs in a national sample who reported a second position
(13.7%) (NCSBN, 2020). Fewer White PMH-RN respondents held a second nursing position
compared with other racial minority groups. PMH-RN respondents with a second nursing
position reported working an average of 14 hours per week (SD=8.9) at that second position.
Eleven percent of those respondents reported working between 21 and 35 hours per week
in that second position. This pattern held true across gender and age categories. A slightly
larger proportion of male PMH-RNs (17%) and Black or African American PMH-RNs (15%)
reported working between 21 and 35 hours per week, but these were not statistically significant
differences.

EARNINGS

Pre-tax annual income from primary employment was in the $50,000-99,000 range for about
two-thirds of respondents. Income from primary employment tended to increase with age
up to 70 years and then decreased. Nurse administrators most frequently reported earning
greater than $100,000 annually, followed by nurse managers and those working in correctional
facilities.

PMH-RN respondents who reported earning less than $75,000 annually included a
disproportionate number of American Indian and Alaskan Native PMH-RNs and those
employed in rural counties. PMH-RN respondents who reported earning less than $50,000
annually were more likely to report working in school-based clinics and in home psychiatric
care. There were no differences in earnings by identified gender. This differs from the finding
in a national sample of RNs that males have a higher median salary compared with females
across all nursing specialties (NCSBN, 2020). Figure 4 shows the distribution of annual salary
across the PMH-RN respondents.

Provision of
telehealth

secondary
employment
setting

17Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

DISCUSSION

This report describes the demographic, education, employment characteristics, and earnings
reported by PMH-RNs surveyed by the American Psychiatric Nurses Association (APNA) in
2020-2021. Key findings from this survey have significant implications for practice, education,
policy, and research.

Our findings suggest that the PMH-RN workforce is aging, similar to the national registered
nursing workforce sample (Smiley et al., 2021). However, there are fewer PMH-RNs in the 20-
29 age range compared with the national RN sample suggesting that younger nurses are not
entering the psychiatric-mental health nursing field.

This finding should be considered in light of the fact that younger nurses may not have ANCC
certification or are not in the APNA database as they have not been socialized to the role of the
professional PMH-RN.

The top two reasons respondents reported as barriers to becoming a PMH-RN are that
individuals felt they needed medical-surgical experience and that a faculty member told them
they needed medical-surgical experience prior to becoming a PMH-RN. These findings are
consistent with research that suggests there is a stigma associated with specializing in PMH
nursing and that the negative view of PMH nursing is perpetuated by nursing faculty (Ben
Natan, Drori, & Hochman, 2015; Halter, 2008).

Recent research has identified that PMH nurses have difficulty articulating their value and
expertise (Lakeman & Hurley, 2021). The small number of younger nurses entering PMH
nursing and nursing faculty promulgating the belief that nurses need medical surgical
experience prior to practicing in PMH nursing have far reaching implications for education.
Pre-licensure nursing programs should re-envision the delivery of PMH nursing education
by providing students with opportunities outside of the hospital that capitalize on the broad
knowledge and skills of PMH-RNs (Delaney, 2016; Kaas, 2020). This could be accomplished, in

Aging of
Psychiatric-
mental health
Rns

Pmh-Rn Annual salary
Figure 5

0
200
400
600
800

1000
1200

< $
15,0

00

$15
,00

0-$29
,999

$30
,00

0-$49
,999

$50
,00

0-$74
,999

$75
,00

0-$99
,999

$10
0,0

00-$
150,0

00

$15
0,0

00-$
200,0

00

> $
200

,000

RN Annual Salary Distribution
1200

$15,000 $15,000-
$29,999

$30,000-
$49,999

$50,000-
$74,999

$75,000-
$99,999

$100K-
$150K

$150K-
$200K

$200K +
0

18Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

part, by nursing programs developing academic-practice partnerships and exposing students
to diverse roles of PMH-RNs (Kaas, 2020; Phoenix, 2019).

PMH-RNs have a different racial and gender composition than a national sample of RNs. While
the majority of both groups of nurses are White, the second most frequently reported race
among PMH-RNs is Black or African American, while the second most frequently reported
race among the 2020 national registered nurse sample is Asian. In addition, the proportion
of respondents that identified as Black or African American in the PMH-RN sample is double
that of the national RN sample. Only 4% of respondents identified as Latinx suggesting a
significant underrepresentation of this ethnic subgroup compared with the general population
which has far reaching implications for the diversity of the nursing workforce. Further, a greater
proportion of PMH-RNs identified as multiracial compared with the national RN sample.
Finally, males comprise a greater proportion of the PMH-RN population compared with their
male counterparts in the national sample. The greater proportion of males in the PMH-RN
workforce compared with the general RN population and the disparity between the percentage
of Hispanics in the general population compared with the PMH-RN workforce has been
documented previously (Phoenix, 2019).

Compared with a national sample of RNs, more PMH-RNs reported a hospital as their primary
employment setting. Future research should examine trends in PMH-RN employment.
Consistent with previous reports, very few PMH-RNs are working in rural locations, which
contributes to the service gap in these areas (Phoenix, 2019).

Findings about services provided could shed light on the role of PMH-RNs in mental health
settings. The majority of respondents reported that they assess physical health status,
assess mental health status, and educate patients and families for most patients. Less than
half of respondents reported that they provide care coordination, therapeutic relationship
and counseling, crisis management, and milieu therapy for most patients. Recent literature
suggests a lack of role clarity and shared vision among PMH-RNs and the need for discourse
that articulates the value and expertise of PMH nurses (Hurley & Lakeman, 2021; Salberg,
Bäckström, Röing, & Öster, 2019). It should be noted that the majority of the literature on the
role of PMH-RNs has been conducted outside of the United States.

Less than two-thirds of respondents reported feeling ‘safe’ or ‘very safe’ at work. Patient acuity,
level of administrative support, staffing ratio, and level of staff were reported as factors that
influenced safety. Patient acuity was the most cited factor influencing perceptions of safety for
PMH-RNs ages 20 through 50, while level of administrative support was the most cited factor
influencing perceptions of safety for PMH-RNs greater than age 50.

Feelings of safety increased with increased experience and education. Research has identified
high rates of violence in psychiatric treatment settings and risk factors for that violence such
as gender, job function, years of experience, and patient diagnosis (Odes, Chapman, Harrison,

diversity

employment
setting

services
Provided

Perceptions of
safety

19Pmh-Rn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Ackerman, & Hong, 2021). Research shows that perceived risk of assault, lack of leadership,
inadequate staffing, and demanding work schedules negatively impact retention (Adams,
Ryan, & Wood, 2021). Increased acuity in inpatient psychiatric settings has been attributed to
decreased length of stay and increased throughput of admissions, transfers, and discharges. It
is not known if the facilities in which the PMH-RNs are employed use an acuity tool to stratify
patients for assignments and to determine staffing. Future research should examine the
use of tools to measure patient acuity and the reliability of these tools to predict perceived
levels of safety. Research should also examine the types of training PMH-RNs receive by their
employers related to management of high acuity patients.

In summary, PMH-RNs stand ready to provide integrated care interventions to vulnerable
populations, but there is little data available to describe these specialized RNs (Merwin,
2020). Further, PMH-RNs contribute to the health and recovery of persons with mental health
disorders and have the potential to transform care delivery (Gabrielsson, Tuvesson, Wiklund
Gustin, & Jormfeldt, 2020). This report is an initial attempt to fill the gap in data related to the
PMH nursing workforce. Ongoing collection of the demographic, education, and employment
data on PMH-RNs will inform behavioral health workforce planning and program and policy
development.

summary

20Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

PMH-APRN SURVEY FINDINGS

Psychiatric-Mental Health Advanced Practice
Registered Nurse Survey Findings

EXECUTIVE SUMMARY

This section of this report contains data on the demographics of the current Psychiatric-
Mental Health Advanced Practice Registered Nurse (PMH-APRN) workforce and their
demographics, educational preparation, practice settings, clinical activities, and earnings.

The average age of PMH-APRNs is 54 years, with more than half of the respondents in their
50s or 60s. Twenty seven percent of respondents plan on retiring in the next six years, with
a greater percent of intended retirements among Clinical Nurse Specialists (CNS). Although
the majority of PMH-APRNs are White (86%), the proportion of respondents that identified
as Black or African American in the PMH-APRN sample is slightly larger than the broader
Nurse Practitioner (NP) population, but less diverse in terms of PMH-APRNs who identify as
Hispanic/Latino. The sample largely is female and the proportion of males (10%) reflects the
gender distribution of the broader NP population.

A majority of the sample reported a Master of Science (MSN) as their highest degree, and
their initial PMH-APRN preparation. A significant percentage of respondents were prepared at
the Doctor of Nursing Practice (DNP) level (12%) and a smaller number of PMH-APRNs hold
a Doctor of Philosophy as their highest degree. The number of respondents completing their
graduate degree since 2010 almost doubled, which mirrors the reported increase in ANCC
certifications over the last 10 years. A small number of respondents (11%) reported completing
a Post-Masters Residency and they were generally satisfied with the program. A PMH-NP
(lifespan) was the most common certification with noted differences by age; older PMH-
APRNs were more likely to hold a CNS certification.

A majority of respondents (70%) practice in a range of outpatient settings, including mental
health clinics, private practice, federally qualified health centers, and community health
centers. Approximately 88% of respondents prescribe as well as provide diagnosis and
management services to most patients. A significant portion combine prescribing with
psychotherapy (69%) but a much smaller percentage of respondents provide any type of
stand-alone psychotherapy. Approximately 42% of respondents completed Medication for
Addiction Treatment (MAT) training and, of these, 72% subsequently applied for a Drug

overview

demographics

education and
certification

employment
characteristics

21Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Enforcement Administration (DEA) X-waiver to prescribe Buprenorphine for opioid use
disorders. A majority of respondents treat patients who hold commercial insurance or
Medicaid/Medicare, with 44% stating most of their clients were covered by federal insurance.
These findings indicate that PMH-APRNs play an important role in providing care to
underserved populations.

Pre-tax annual income from primary employment was in the $100,000-150,000 range for 47%
of respondents. Males reported higher income ranges. There was no mean income difference
based on race. The majority of respondents indicated they have a 40-hour work week. The only
group that works significantly fewer hours is PMH-APRNs whose primary employment setting
is educational, who reported 19-26 hours per week.

FULL DATA FROM THE APNA PMH-APRN SURVEY

In some instances, data from the PMH-APRN survey are compared with data from the American Association of
Nurse Practitioner (AANP) 2020 National Practitioner Sample Survey, which includes a nationally representative
sample of all NPs.

DEMOGRAPHICS

The average age of the 4,354 PMH-APRNs who responded to the survey is 54.1 years ranging
from 25 to 88 years old. Age is calculated by participant responses to date of birth. The
average age of these respondents is older than the average age of NPs reported nationally
which is 49 years (AANP, 2021). More than half of the respondents (53%) are in their 50s or
60s. In the AANP (2021) sample 37% of NPs were over 55 years old. The age of PMH-APRNs
varies by certification: PMH-NP-lifespan certification holders’ median age is 48 years versus
66 years for PMH-CNSs. (See Figure 6.) The large number of PMH-APRNs in their 50s and 60s
represents a significant context for many other observations in this report.

earnings

Age

*scale approximate

35 Years 70 Years0

OVERALL (n=4,354)

PMH-CNS Child and Adolescent (n=225)

PMH-CNS Adult (n=951)

PMH-NP Adult (n=810)

PMH-NP Family/Lifespan (n=2,324)

type of Pmh-APRn certification by median Age of Respondents
Figure 6*

22Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 4,364 PMH-APRNs who responded, 88% reported their gender as female, 10% reported
male gender, and 0.44% reported either non-binary or transgender. Similarly, 89% were
assigned female on their original birth certificate while 10% were assigned male; a percentage
close to the reported national gender distribution for all NPs (10% male) (Kaiser Family
Foundation, 2021).

Of 4,364 PMH-APRNs responding, 80% identified as White and approximately 20% of
respondents identified as racial or ethnic minorities. The second most frequently identified
race in our sample was Black or African American (10%) which is slightly higher than the
national sample of NPs who identified as Black (8%) (AANP, 2021). However, compared with
the NP national sample, only 2% of the PMH-APRN respondents identified at Latinx compared
to 5% of NPs in the national sample (AANP, 2021). In addition, 2% of the sample identified as
American Indian or Alaskan Native and 0.5% as Native Hawaiian or Pacific Islander. (See Figure
7 for racial distribution among the sample of PMH-APRNs.) Given the growing Hispanic/Latinx
US population (18%) (US Census Bureau, 2020), the low percentage of PMH-APRNs of similar
ethnic identity is concerning. It should be noted that 0.4% of respondents said they spoke
Spanish.

Fewer than 10% of responding PMH-APRNs have any relationship to the military: 6% have been
on active duty in past, 3% currently serve in the National Guard or Reserves, and 0.9% are
currently on active duty.

gender, sex,
and sexual
orientation

Race/ethnicity

Active duty
service

4000

3500

3000

2500

2000

1500

500

0

1000

White Black or
African

American

Asian Latinx American
Indian or
Alaskan
Native

Native
Hawaiian
or Pacific
Islander

Race as identified by survey Respondents
Figure 7

23Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

HUMAN CAPITAL

Of 4,938 respondents, the overwhelming majority (82%) reported that their initial PMH-
APRN preparation was via completion of an MSN degree. This does not vary meaningfully
by age or race. In the past 10 years about 12% of respondents have received a DNP as their
initial preparation, with similar proportions of respondents in their 30s or 40s being prepared
initially as DNPs. (See Figure 8.) These data mirror national NP trends showing 95% of NPs
reporting their initial preparation was a Master’s degree, with 17.9% holding a DNP (AANP,
2021). Interestingly, approximately 36% of respondents completed their initial PMH-APRN
preparation in the 2010 decade, almost double the number completing their initial degree in
the 2000s. These data reflect the rapid growth of the PMH-APRN workforce. Indeed, ANCC
certification data indicate from 2013 to 2020 the total number of certified PMH-APRNs nearly
doubled; from 13,393 PMH-APRN in 2013 to 26,690 in 2020 (ANCC, 2013; 2020). Of note, 10%
of respondents completed a PMH Post-Master’s Certificate as their initial role preparation.
This number also doubled for those earning Post Master’s Certificates in 2000s
to those completing this preparation in the 2010s.

For respondents under 50, more than 40%, on average, of the didactic coursework was online.
For those in their 20s, more than a quarter reported that 100% of the didactic coursework was
online, and for those in their 30s, a quarter reported 85% of coursework was online.

education

Percentage of
coursework
online
for initial
Pmh-APRn
education

Other

Other Nurse Practitioner (NP)

Family Nurse Practitioner (FNP)

Doctor of Nursing Practice (DNP)

Master of Science in Nursing
(MSN)

PMH-APRN Post-Master’s
Certificate

0%

10%
20%

30%

40%

50%

60%

70%
80%

90%

100%

1960’s 1970’s 1980’s 1990’s 2000’s 2010’s

Educational program for initial APN preparation X year of
Degree Completion

Other

Other NP

FNP

Doctor of Nursing Practice (DNP)

Master’s of Science in Nursing
(MSN)

Psychiatric Mental Health APRN
Post-Master’s Certificate

1960s 1970s 1980s 1990s 2000s 2010s

0%

100%

50%

initial type of Pmh-APRn Preparation by year of degree completion
Figure 8

24Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 5,012 respondents, 11% completed a post-graduate residency or fellowship program. This
did not meaningfully vary by age, gender, or race. The proportion of respondents with a post-
graduate residency or fellowship increased slightly with age, but the sample sizes were too
small to establish statistical significance. For 516 respondents who completed a residency, the
typical program was either 12, 18, or 24 months. About 86% of the PMH-APRN respondents
who completed a residency or fellowship program reported that they were either satisfied or
very satisfied with the program.

Approximately 17% of PMH-APRN respondents hold a DNP, which is slightly higher than the
national NP cohort who earned a DNP (15%) (AANP, 2021). In addition, the number of PMH-
APRNs holding a DNP doubled from the 2000 to the 2010 decade. The majority (69%) of the
PMH-APRN respondents reported their highest degree as a Master of Science in Nursing
(MSN), which is slightly lower than the AANP (2021) survey which found that 81% of NPs
reported an MSN as their highest degree earned. (See Figure 9.) There are no differences
in highest degree earned by race or certification. An interesting aspect of the educational
trajectory of respondents is that close to 41% completed a diploma or Associate degree
program for their initial RN license; this speaks to career mobility within PMH nursing.

Respondents included those licensed in all 50 states, as well as Washington, DC. About three
quarters of respondents were licensed in one state, and 23% licensed in 2 to 4 states. Eighty-
seven percent of respondents are currently certified by ANCC. Four states do not require NPs
to have a national certification to practice (California, New York, Kansas, and Indiana). PMH-NP
Family/Lifespan is the most common certification of the respondents, but there are significant
differences in certification types by age. Generally speaking, PMH-APRNs in their 60s and
above are more likely to be certified as a CNS than as an NP and more focused on the adult
population. Younger PMH-APRNs increasingly hold PMH-NP Family/Lifespan certifications.

new graduate
Residency or
fellowship
Program
education

highest
degree earned

state
licensure and
certification

1960s 1970s 1980s 1990s 2000s 2010s

Other

PhD in Nursing

Doctor of Nursing Practice

PMH-APRN Post-Master’s
Certificate

Post-Master’s Certificate

Master of Science in Nursing
(MSN)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1960’s 1970’s 1980’s 1990’s 2000’s 2010’s

Highest level of nursing education x year of initial APN
program completion

Other

PhD in Nursing

Doctor of Nursing Practice

Psychiatric Mental Health APRN
Post-Master’s Certificate

Post-Master’s Certificate

Master’s of Science in Nursing
(MSN)

0%

100%

50%

highest level of nursing education by year of completion
Figure 9

25Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Figure 10 shows that the distribution of certification types is influenced by ANCC certification
exams currently available.

Generally, the number of PMH-APRN survey respondents was greatest in large, highly
populated states, such as New York, California, Florida, and Texas, that have generally low
state density of PMH-APRNs. Two exceptions are Massachusetts and Washington, which
ranked third and fourth among state respondents to the survey and also have higher state
densities of PMH-APRNs.

Understanding PMH-APRN distribution requires calculating PMH-APRN providers per state
per 100,000 population. In this regard our respondent distribution no longer mirrors national
data. For instance, while a large number of survey respondents were from California, that state
has one of the lowest ratios of PMH-APRNs per 100,000 population (2.15) in the US (Beck et
al., 2018). While PMH-APRN state density is important, no inferences can be drawn from our
data on this point. However, the report from Beck and colleagues (2018) contains the most
recent data on state level PMH-APRN density, indicating the highest ratios of PMH-APRNs
per 100,000 in the Northeast states (Maine (22.0), Massachusetts (17.6); Rhode Island (16.6)
Connecticut (16.2) and Vermont (14.9) and the lowest ratio of PMH-APRNs per 100,000 in
Illinois (2.8), Nevada (2.8), West Virginia (2.5), California (2.1), and Oklahoma (1.5).

Approximately 27% of respondents plan to retire in the next six years, 7% in the next one to two
years. This is not surprising given that 40% of PMH-APRN respondents are over 60 years old.
Retirement plans vary by certification, with a greater percent of PMH-CNSs indicating plans
to retire in the next 6 years, 55% of Adult PMH-CNSs and 51% of Child and Adolescent PMH-
CNSs. The CNS group has a higher mean age and thus this retirement rate is anticipated. (See
Figure 11.)

Plans for
Retirement

current certification held by Respondents by Age
Figure 10

0%
20%
40%
60%
80%

100%

PMH CNS Child and
Adolescent

PMH CNS Adult PMH NP Adult PMH NP Family /
Lifespan

Never Certi fied

Age by Current Certification

20’s 30’s 40’s 50’s 60’s 70’s 80’s

0%

100%

PMH-CNS Child
and Adolescent

PMH-CNS Adult PMH-NP Adult PMH-NP Family/
Lifespan

Never Certified

20-29 30-39 40-49 50-59 60-69 70-79 80-89

26Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

EMPLOYMENT CHARACTERISTICS

Of the 4,703 PMH-APRNs who responded, 70% practice in outpatient settings. The next
largest employment site is hospitals (16%). Respondents also work in correctional facilities
(2%) and as educators with a practice component (4%). (See Figure 12.) Employment in an
outpatient setting is not statistically impacted by age, race, or gender. Primary employment
setting is influenced by year of graduation, with more recent graduates less likely to be
employed in a college/university or hospital setting and more likely to practice in an outpatient
setting.

Those respondents who practice in an outpatient setting specified the type. A significant
number of PMH-APRNs now practice in FQHCs and mental health clinics and fewer PMH-
APRNs practice in private practice, either in a PMH-APRN or MD office. A significant segment
of PMH-APRNs practice in integrated care and substance use treatment. (See Figure 13.)
Of the PMH-APRNs practicing in hospitals (n = 646), the largest percentage of respondents
practice in public general hospitals (28%) and city, county, or state psychiatric hospitals (16%)
with more recent graduates (since 2010) making up half of the PMH-APRNs practicing in
these sites. Of the 4,215 PMH-APRNs who responded to the question on hospital admitting
privileges, 82% indicated they do not have hospital admitting privileges.

Eighty-eight percent of respondents reported their employment setting is in a metropolitan
county. Only 1% are in a rural county (defined as both rural AND not adjacent to a metropolitan
area). Alaska has the highest proportion of rural PMH-APRNs (10%). Of interest is if state

Primary
employment
setting

Retirement Plans by certification type
Figure 11

0%

50%

100%

OVERALL
(n=4,128)

PMH-APRN
(n=3,671)

PMH-CNS
Child and

Adolescent
(n=191)

PMH-CNS
Adult

(n=845)

PMH-NP
Adult

(n=776)

PMH-NP
Family/Lifespan

(n=2,284)

< 1 year 1-2 years 3-4 years 5-6 years 7-8 years 9-10 years 10-15 years 15+ years Undecided

27Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

requirements restricting practice have an impact on PMH-APRN distribution, particularly in
rural areas, since it may be more difficult to secure a collaborating physician in regions which
are traditionally health professional shortage areas. This relationship has been difficult to
demonstrate (Ortiz et al., 2018). One recent labor analysis of PMH-APRN practice, however,
concluded that if more states granted Nurse Practitioners professional independence it could
encourage an increase in available working time and encourage practice with populations and
in regions that are underserved (Luo, Escalante & Taylor, 2021). As the PMH-APRN workforce
grows, state distribution and the provision of rural mental health services will be an important
area of workforce research.

0 500 1000 1500 2000 2500 3000 3500

Ambulatory/Outpatient
Hospital

Education/Academic (With Faculty Clinical Practice)
Education/Academic (No Clinical Practice)

Correctional facility
College/University Counseling Center

Community residential
School-Based Clinic

Retired
Other

Primary Employment Area
Primary employment setting of Respondents

Figure 12

0 500 1000 1500 2000 2500 3000 3500

Other
Retired

School-Based Clinic
Community/Residential

College/University Counseling Center
Correctional Facility

Education/Academic (No Clinical Practice)
Education/Academic (w/ Faculty Clinical Practice)

Hospital
Ambulatory/Outpatient

type of outpatient employment setting by year of Pmh-APRn degree completion
Figure 13

0%

50%

100%

OVERALL
(n=3,195)

1960s
(n=5)

1970s
(n=133)

1980s
(n=322)

1990s
(n=492)

2000s
(n=690)

2010s
(n=1,553)

Academic Federal VA Mental Health Clinic Substance Use/Addiction Treatment Center Other
Academic Medical Setting FQHC Primary or Specialist Medical Care Community Health Center

Federal DOD Integrated Care Private Practice MD Hospital Private Practice

28Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of the 4,329 respondents, 86% indicated they provide telehealth services in their employment
settings. On average, they provide these services in two states, to an average of 25 patients
per week. Since the survey was conducted at the start of the COVID-19 pandemic, these
numbers may represent only a fraction of telehealth services provided in the last two years.

Of 4,305 respondents, approximately 44% indicated that they are precepting students in a
clinical setting. On average, these respondents precept four students per year.

Over half (55%) of the 4,342 respondents to this question indicated they billed under their
National Provider Indicator (NPI) number, the majority of whom practice in an ambulatory or
outpatient setting. Of this group, one-quarter indicated they did not know if the billing occurred
under their own NPI number. When asked about payment, 38% of respondents indicated that
some of their patients used commercial insurance, while 44% of respondents reported that
most of their patients use Medicare/Medicaid.

There were three survey questions on provision of Medication for Addiction Treatment (MAT)
for opioid use disorders. Approximately 42% of respondents (1,767) had completed MAT
training, 60% of whom graduated since 2000. (See Figure 14.) Of the 1,273 respondents who
indicated they completed MAT training, 72% subsequently applied for the DEA X-waiver.
Of these respondents, 32% reported that they had a 30-patient waiver limit and 40% had a
100-patient limit, with half of respondents indicating they would increase their waiver limit
when eligible. At the state level, 75% of states have approximately two-thirds of respondents
applying for the waiver; however, some states have as few as 30% applying for the waiver. This
finding may be related to limitations on PMH-APRN scope of practice in specific states, since
PMH-APRNs are less likely to be waivered in states that require physician supervision (Spetz
et al., 2021).

telehealth
services

Precepting
students

billing for
services

Provision of
substance use
services

OVERALL

100%

0%

1960s 1970s 1980s 1990s 2000s 2010s

Respondents who
completed mAt

training by year of
graduation

Figure 14*

*scale approximate

29Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

Of 4,780 respondents, 88% reported having prescriptive authority. Those holding PMH-NP
certifications had much higher rates of prescriptive authority (98%), and those with PMH-
CNS certifications significantly lower; however, a substantial number of PMH-CNSs do
prescribe (66%). (See Figure 15). Prescriptive authority decreases with years since graduation
and increases with those graduating since 2010; 97% of these more recent graduates have
prescriptive authority. This is likely because most PMH-APRN graduates during this period
completed PMH-NP programs.

The majority of respondents indicated they work 40 hours per week. The only group that works
significantly fewer hours is PMH-APRNs whose primary employment setting is educational,
who work 19-26 hours per week. This group is likely the approximately 4% of respondents who
indicated they held an academic position and maintain a practice; thus, the number of practice
hours may reflect their dual position.

Respondents were asked to indicate services they provided to none, few, some, or most
patients. In these queries, respondents indicated that for most patients they prescribed
medications (76%), conducted diagnostic evaluations (66%), ordered lab tests and diagnostic
studies (41%), provided education (81%), and provided care coordination (43%). Services
not provided to a majority of patients included conducting physical exams (14%), providing
preventive services such as immunizations (17%), and making referrals (29%). While a small
percentage of PMH-APRNs indicated they provide substance use services to most patients
(13%), more than one quarter of PMH-APRNs (31%) provide these services to some patients.
(See Figure 16.)

In terms of therapy, a significant portion of respondents provided crisis intervention services
to some patients (41%), and fewer PMH-APRNs provided crisis services to most patients
(17%). Close to half of respondents (48%) provide psychotherapy combined with medication
management to most patients. Fewer respondents provided individual psychotherapy to

Prescriptive
Authority

Practice hours

services
Provided

OVERALL
(n=4,780)

100%

0%

50%

PMH-NP
Family/

Lifespan
(n=2,494)

PMH-NP
Adult

(n=892)

Never
Certified
(n=258)

PMH-CNS
Child and

Adolescent
(n=245)

PMH-CNS
Adult

(n=1,072)

Prescriptive Authority
by certification

Figure 15*

*scale approximate

30Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

most patients (10%), or provided group therapy (3%), family therapy (2%), or child/adolescent
psychotherapy (4%) to most patients. (See Figure 17.)

90%

0%

services Provided in Primary work setting
Figure 16

None Few Some Most

Prescribing/
Medication

Diagnostic
Evaluation

Psycho-
education

Case
Management

Consultation
Liaison

Substance
Use Services

90%

0%

therapy services Provided in Primary work setting
Figure 17

None Few Some Most

Psychotherapy
and

Prescribing/
Medication

Crisis
Intervention

Individual
Psychotherapy

Without
Medication

Group
Psychotherapy

Couples
Therapy

Child and
Adolescent

Psychotherapy

Family
Psychotherapy

31Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

EARNINGS

Nearly half of the 4,288 PMH-APRN respondents (47%) indicated they earned between
$100,000-150,000 per year; 13% indicated earning less ($75,000-99,000), and 11% reported
earning more ($150,000-200,000). A higher percentage of males are in the upper income
bracket. (See Figure 18.) These data are in line with the AANP (2021) survey that place PMH-
NPs as the highest paid group of NPs by certification (average $136,000 total income).

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%

100%

OVERALL
(n=3912)

Female (n=3421) Male (n=402) Non-Binary (n=9) Transgender
(n=5)

Pre-Tax Income By Gender

Under $15,000 $15,000 – $29,999 $30,000 – $49,999 $50,000 – $74,999

$75,000 – $99,999 $100,000 – $150,000 $150,000 – $200,000 Over $200,000

Reported income by gender
Figure 18

0%

50%

100%

OVERALL
(n=3,912)

Female
(n=3,421)

Male
(n=402)

Non-Binary
(n=9)

Transgender
(n=5)

< $15,000 $15,000-$29,999 $30,000-$49,999 $50,000-$74,999
$75,000-$99,999 $100,000-$150,000 $150,000-$200,000 $200,000+

32Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

DISCUSSION

This report describes the demographic, education, employment characteristics, and earnings
reported by PMH Advanced Practice Nurses who were surveyed by the American Psychiatric
Nurses Association in 2020-2021. Key findings from this survey have significant implications for
practice, education, policy, and research.

The demographics of PMH-APRN respondents are similar to those reported in national NP
workforce surveys except for the percentage who identified as Latinx. Compared with the
NP national sample where 5% of respondents identified as Hispanic (AANP, 2021), only 2%
of the PMH-APRN respondents identified as Latinx. Given the growing Hispanic/Latinx US
population (18%) (US Census Bureau, 2020), the low percentage of PMH-APRNs of similar
ethnic identity is an opportunity for improvement. It is well documented that the racial/ethnic
composition of the behavioral health care workforce does not mirror the populations needing
and seeking mental health services, and the challenges in addressing this disparity are
significant (Buche, Beck, & Singer, 2017). With growing emphasis on increasing diversity in the
RN workforce, there is an opportunity to strategize how to improve diversity beginning at the
level of PMH-NP educational programs (Gates, 2018). Younger cohorts of RNs are generally
more racially diverse than those who are older than 55 and the percentage of RNs who identify
as Hispanic/Latinx is slowly increasing (Smiley, et al., 2021), which will create opportunities to
recruit more diverse cohorts of PMH-NP students.

The PMH-APRN workforce mirrors the national NP workforce in many respects, save average
age. Owing to the longevity of the PMH-APRN certification, the profession built a substantial
PMH-CNS workforce throughout the 1970’s (Drew, 2014). As these valued PMH-APRNs begin
retirement, it is critical to monitor the growth of PMH-NP workforce. It appears PMH-NP
workforce growth is accelerating, with 2020 PMH-NP lifespan certifications demonstrating
a 30% increase over 2019 (ANCC, 2021). Given that PMH-APRNs are one of four professions
licensed to provide the full range of mental health services, sustaining this workforce is vital
to the provision of mental health care, particularly given the small numbers of Psychiatric
Pharmacists (996), Physician Assistants specializing in psychiatry (1,164), and the diminishing
number of practicing psychiatrists (Beck et al., 2018). Demand for psychiatric services is
projected to exceed the supply by 15,600 workers (25%) in 2025 (National Council, 2017), a
demand that will undoubtedly be even higher given the impact of the COVID-19 pandemic on
mental health (Pfefferbaum & North, 2020). Thus, maintaining the size and capabilities of the
PMH-APRN workforce is vital.

PMH-APRNs focus on the critical tasks of primary mental health care: diagnosis, management,
prescribing, and treatment monitoring. The vast majority of PMH-APRNs provide these
services to most patients they treat. As PMH-APRNs move into providing comprehensive
outpatient mental health care, our respondents’ lack of hospital admitting privileges may
become a significant barrier to accessing services needed by clients in acute distress.

demographics

Retirements

clinical focus

33Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

While providing psychotherapy alone is rare, close to 70% of respondents said they provide
psychotherapy and medication management to some or most patients. As the role of the
PMH-APRN vis-a-vis psychotherapy continues to be debated (Scheydt, & Hegedüs, 2021), in
line with our data, prescribing combined with psychotherapy is the dominant practice and its
outcomes should be examined.

The data indicate that PMH-APRNs are increasingly likely to practice in outpatient settings,
particularly mental health clinics and FQHCs. These data mirror national trends of increasing
NP roles in the delivery of care at these sites (Yang et al., 2017) and their importance in
reaching the underserved (Xue et al., 2019). Data indicate a large percentage of recent
graduates have completed MAT training, demonstrating that this group can be a vital resource
for closing disparities in opioid treatment (Andrilla et al., 2020). Over three quarters of NP
educational programs report implementing curricular modifications to address treatment of
opioid use disorders, which in some programs includes MAT training to provide medication
for addictions treatment (Kameg, et al., 2021). Recommended competencies and content
are in place for increasing the inclusion of substance use competencies into PMH-NP
educational programs (Finnell, Tierney, & Mitchell, 2019) and reports are emerging of how
these competencies/content have been integrated into select PMH-NP programs (Abram,
White, & Jacobowitz, 2020). Thus, these outpatient roles and the capacity of PMH-APRNs to
address gaps in mental health/substance use care should be highlighted to behavioral health
care planning groups, policymakers, and insurers who are now beginning to recognize their
potential contribution in these settings (Pietras & Wishon, 2021).

Almost half of the respondents indicated that most of their patients used Medicare/Medicaid
insurance. Providing services to this population is critical as a significant number of individuals
dealing with serious mental illness are enrolled in these insurances (McGinty, 2020; Ward et
al., 2017) and psychiatrists have low acceptance rates of individuals on these plans, indeed
lower than those for other types of physicians (Bishop et al., 2014). These are some of the most
complex patients and, similarly to the broader universe of NPs, PMH-APRNs are well suited
to provide care and address the significant unmet mental health care needs of this population
(Beeber, 2019; Han et al., 2017). Bishop et al. (2014) also reported that only 55% of psychiatrists
accept fee for service insurance of any type, compared with 89% of physicians in other
specialties. One quarter of our respondents indicated that most patients used commercial
insurance. Emerging data on mental health services with youth indicate the care delivered
by PMH-NPs is of high quality (Yang et al., 2018; 2021). Thus, PMH-APRNs are an important
provider group for increasing access to mental health services for individuals seeking services
since they accept payment via either commercial or federal insurance.

Two noteworthy trends in PMH-APRN education preparation emerged in our data. One is the
number of PMH-APRN programs with increased percentage of content online: more than a
quarter of participants in their 20s reported that 100% of their didactic coursework was online,
and for those in their 30s, a quarter reported 85% was online. While the shift to online didactic

Practice
settings

caring for
insured and
underserved
individuals

shifting
Patterns of
education

34Pmh-APRn suRvey findings | APNA 2022 PMH NURSING WORKFORCE REPORT

education is acknowledged, there is scant direct study of the effectiveness of this delivery
method. There is ongoing interest in the development of clinical competencies, including the
move to adapt the American Association of Colleges of Nursing’s (AACN) competency-based
education model (AACN, 2012).

The second trend is the increased number of recent PMH-NP graduates with DNP
preparation. This mirrors national trends toward adopting the DNP for entry to advanced
practice and which identified PMH-NP as a top population focus in moving from MSN-to-
DNP (46%) (Baldyga & DePaepe, 2021). The PMH-NP BSN-to-DNP program growth has also
been substantial (74% change) (Baldyga & DePaepe, 2021). DNP preparation will produce
graduates with considerable skills in outcome evaluation and quality improvement. This
shift in educational preparation provides an opportunity to focus on how to use DNP project
research in a way that builds our knowledge and evidence base around the nursing approach
to service issues and builds the scholarly output of psychiatric-mental health nurses (Redman
et al., 2015). At the same time the profession should be concerned about the slow growth in
numbers of PMH-APRNs with PhD preparation (Vance et al., 2020). This is mirrored in our data
indicating the PhD degree is held by only 6% of our respondents, with a decreasing percentage
of PMH-APRNs holding a PhD in the cohort graduating since 2010. Nursing research is vital to
the improvement of mental health services and policy development and our profession needs
to maintain focus on ensuring adequate capacity of PhD-prepared psychiatric-mental health
nurses.

35summARy | APNA 2022 PMH NURSING WORKFORCE REPORT

SUMMARY

Report Summary

The final section of this report synthesizes and highlights overall key findings about the
Psychiatric-Mental Health (PMH) nursing workforce, that is—registered nurses (RNs) and
advanced practice registered nurses (APRNs), and their educational preparation, employment
characteristics, and earnings.

The PMH nursing workforce is aging with more than half of the PMH-RN and PMH-APRN
respondents in their 50s or 60s. Only a small percentage of PMH-RNs are in the 20-29 age
range and more than one-quarter of PMH-APRN respondents plan on retiring in the next six
years, with a greater percent of intended retirements among clinical nurse specialists (CNSs).
While the number of students graduating from PMH Nurse Practitioner (NP) programs is
significantly increasing, the profession should monitor the balance between retirements and
PMH-NPs entering practice.

Although the majority of the PMH nursing workforce is White, the proportion of respondents
that identified as Black or African American in our sample is greater than national samples
of RNs and NPs. However, the PMH nursing workforce is less diverse in terms of those
who identify as Hispanic/Latinx. Psychiatric-Mental Health Nurse leaders should focus on
recruiting early-career nurses as well as racial and ethnic minority populations into the field.

About half of the PMH-RN sample reported a Bachelor of Science in Nursing (BSN) as their
highest degree, while the majority of the PMH-APRN sample reported a Master of Science
in Nursing (MSN) as their highest degree and their initial PMH-APRN preparation. Rates of
certification among PMH-RNs vary by race and age with the highest proportion of respondents
certified by the American Nurses Credentialing Center identifying as older and White. Nurses
noted that the top reason for not obtaining certification is because it is not valued by their
employer. For PMH-APRNs, the PMH-NP (Lifespan) was the most common certification with
differences by age; older PMH-APRNs were more likely to hold a CNS certification. These
findings are due, in part, to the types of certifications available through ANCC.

PMH-RNs and PMH-APRNs are employed in a variety of settings. The majority of PMH-RNs
reported a hospital as their primary employment setting while the majority of PMH-APRNs
reported the outpatient setting as their primary employment setting. Services provided
by PMH-RNs and PMH-APRNs are consistent with the scope of practice for these roles.
Specifically, the majority of PMH-RN respondents reported that they assess physical health
status, assess mental health status, and educate patients and families for most patients. The
majority of PMH-APRN respondents prescribe as well as provide diagnosis and management
services to most patients. A significant portion of PMH-APRNs also combine prescribing
with psychotherapy (69%) but a much smaller percentage of respondents provide any type of

36summARy | APNA 2022 PMH NURSING WORKFORCE REPORT

stand-alone psychotherapy. Less than half of PMH-APRN respondents completed Medication
for Addiction Treatment (MAT) training and, of these, 72% subsequently applied for a DEA
X-waiver to prescribe Buprenorphine. Finally, a majority of PMH-APRN respondents treat
patients who hold commercial insurance or Medicaid/Medicare, with 44% stating most of their
clients were covered by federal insurance. Few PMH-RNs and PMH-APRNs reported working
in a rural setting.

Pre-tax annual income from primary employment for PMH-RNs was in the $50,000-99,000
range for about two-thirds of respondents. Income from primary employment tended to
increase with age up to 70 years and then decreased. Nurse administrators most frequently
reported earning greater than $100,000, followed by nurse managers and those working in
correctional facilities. PMH-APRN pre-tax annual income from primary employment was
greater than that reported by PMH-RNs with almost half of PMH-APRN respondents reported
earnings in the $100,000-150,000 range. While there was no mean income difference among
PMH-APRNs based on race, males reported higher income ranges.

This report is an initial attempt to fill the gap in data related to the PMH nursing workforce.
Ongoing collection of the demographic, education, and employment data on the PMH Nursing
Workforce will inform behavioral health workforce planning, program, and policy development.

37RefeRences | APNA 2022 PMH NURSING WORKFORCE REPORT

REFERENCES

References

PMH-RN SECTION:

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