Enhancing Psychiatric Mental Health Nurse Practitioner Practice: Impact of State Scope of Practice Regulations


      Shortages of behavioral health providers, particularly prescribing clinicians, are widespread nationally. Although rapidly increasing numbers of psychiatric mental health nurse practitioners (PMHNPs) could increase access to behavioral health services, state limitations on scope of practice may restrict their ability to do so.


      The purpose of this comparative case study was to assess how state scope of practice regulations impact PMHNP practice in five states with different levels of nurse practitioner autonomy (full, reduced, and restricted), as categorized by the American Association of Nurse Practitioners.


      Site visits and interviews were conducted with 94 key informants, including state board of nursing staff, PMHNP practitioners and educators, behavioral health agency directors, and psychiatrists. State scope of practice regulations were reviewed. Thematic analysis was used to analyze qualitative data.


      Findings indicated that scope of practice regulations affected settings and arrangements in which PMHNPs practiced. In states where physician supervision is required, PMHNPs and agency leaders reported costs and administrative burdens related to obtaining and documenting supervision. PMHNP practice was sometimes constrained by institutional restrictions not required by law.


      Mandated physician supervision of PMHNPs adds cost and diminishes accessibility to both psychiatrists and PMHNPs. Full nurse practitioner practice authority allows for more efficient utilization of PMHNPs and may increase access to services.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Nursing Regulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • 244 CMR 4.00: Advanced practice registered nursing
        (Retrieved from)
        • American Association of Nurse Practitioners
        State practice environment.
        2018, December 20 (Retrieved from)
        • Carolina Partners
        Doctors without bosses.
        (Retrieved from)
        • Chapman S.A.
        • Phoenix B.J.
        • Hahn T.E.
        • Strod D.C.
        Utilization and economic contribution of psychiatric mental health nurse practitioners in public behavioral health services.
        American Journal of Preventive Medicine. 2018; 54: S243-S249
        • Conover C.
        • Richards R.
        Economic benefits of less restrictive regulation of advanced practice nurses in North Carolina.
        Nursing Outlook. 2015; 63: 585-592
        • Creswell J.W.
        Qualitative inquiry & research design.
        2nd ed. Sage Publications, Thousand Oaks, CA2007
        • Delaney K.R.
        Psychiatric mental health advanced practice nursing workforce: Capacity to address mental health professional workforce shortages.
        Psychiatric Services. 2017; 68: 952-954
        • Fung Y.L.
        • Chan Z.
        • Chien W.T.
        Role performance of psychiatric nurses in advanced practice: A systematic review of the literature.
        Journal of Psychiatric and Mental Health Nursing. 2014; 21: 698-714
        • Garfield R.L.
        • Lave J.R.
        • Donohue J.M.
        Health reform and the scope of benefits for mental health and substance use disorder services.
        Psychiatric Services. 2010; 61: 1081-1086
        • Hanrahan N.P.
        • Hartley D.
        Employment of advanced-practice psychiatric nurses to stem rural mental health workforce shortages.
        Psychiatric Services. 2008; 59: 109-111
        • Hooker R.S.
        • Muchow A.N.
        Modifying state laws for nurse practitioners and physician assistants can reduce cost of medical services.
        Nursing Economic$. 2015; 33: 88-94
        • Martin B.
        • Alexander M.
        The economic burden and practice restrictions associated with collaborative practice agreements: A national survey of advanced practice registered nurses.
        Journal of Nursing Regulation. 2019; 9: 22-30
        • National Association of Clinical Nurse Specialists
        CNS prescriptive authority by state.
        2015, October (Retrieved from)
        • National Council Medical Director Institute
        The psychiatric shortage: Causes and solutions.
        National Council for Behavioral Health, Washington, DC2017, March 28
        • Neff D.F.
        • Yoon S.H.
        • Steiner R.L.
        • Bejleri I.
        • Bumbach M.D.
        • Everhart D.
        • Harman J.S.
        The impact of nurse practitioner regulations on population access to care.
        Nursing Outlook. 2018; 66: 379-385
        • Noble H.
        • Smith J.
        Issues of validity and reliability in qualitative research.
        Evidence-Based Nursing. 2015; 18: 34-35
        • North Carolina Board of Nursing
        Frequently asked questions.
        2018, August 16 (Retrieved from)
      1. Nurse Practice Act, 225 Ill. Adm. Code § 1300.420 (n.d.). Retrieved from

        • Phoenix B.J.
        • Hurd M.
        • Chapman S.A.
        Experience of psychiatric mental health nurse practitioners in public mental health.
        Nursing Administration Quarterly. 2016; 40: 212-224
        • Poghosyan L.
        • Norful A.
        • Laugesen M.J.
        Removing restrictions on nurse practitioners’ scope of practice in New York state: Physicians’ and nurse practitioners’ perspectives.
        Journal of the American Association of Nurse Practitioners. 2018; 30: 354-360
      2. Pope C. Mays N. Qualitative research in health care. 3rd ed. BMJ Books, Malden, MA2006
        • Quality Assurance Standards for a Collaborative Practice Agreement, 21 N.C. Adm. Code [section symbol] 32M.010
        (Retrieved from)
        • Reagan P.B.
        • Salsberry P.J.
        The effects of state-level scope of practice regulations on the number and growth of nurse practitioners.
        Nursing Outlook. 2013; 61: 392-399
        • Rudner N.
        • Kung Y.M.
        An assessment of physician supervision of nurse practitioners.
        Journal of Nursing Regulation. 2017; 7: 22-29
        • Saloner B.
        • Lê Cook B.
        An ACA provision increased treatment for young adults with possible mental illnesses relative to comparison group.
        Health Affairs (Millwood). 2014; 33: 1425-1434
        • Substance Abuse and Mental Health Services Administration
        Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).
        Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD2018 (Retrieved from)
        • U.S. Department of Health & Human Services, Bureau of Health Workforce
        Designated health professional shortage areas statistics.
        2017, June 30 (Retrieved from)
        • Xue Y.
        • Ye Z.
        • Brewer C.
        • Spetz J.
        Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review.
        Nursing Outlook. 2016; 64: 71-85
        • Yang B.K.
        • Trinkoff A.M.
        • Zito J.M.
        • Burcu M.
        • Safer D.J.
        • Storr C.L.
        • Idzik S.
        Nurse practitioner independent practice authority and mental health service delivery in U.S. community health centers.
        Psychiatric Services. 2017; 68: 1032-1038


      Susan A. Chapman, PhD, MPH, RN, FAAN, is Professor, University of California, San Francisco (UCSF), School of Nursing, Department of Social & Behavioral Sciences.


      Christopher Toretsky, MPH, is Senior Analyst, UCSF Philip R. Lee Institute for Health Policy Studies.


      Bethany J. Phoenix, PhD, RN, FAAN, is Professor, UCSF School of Nursing, Department of Community Health Systems.

      Linked Article

      • Conflict of Interest Compliance Article 4
        Journal of Nursing Regulation Vol. 12Issue 2
        • Preview
          As is standard in scholarly publishing, NCSBN’s Journal of Nursing Regulation (JNR) requires its authors to disclose any potential conflicts of interest (COI). Although COI information has always been collected by our staff in order to support editors’ review of the paper, it was not our standard practice to publish COI statements in each article. In this issue, JNR is retrospectively publishing the COI statements, which were collected with the below papers at submission, in order to make potential COI’s transparent to readers, as well as editors.
        • Full-Text
        • PDF