Editorial: Psychiatric mental health nurse and quality mental health care in the next decade.

The Triple Aim (2008) and Affordable Care Act (2010) established standards for health care delivery and improved access to care, thereby increasing demands on the health care system and its providers. With these reforms, national health leaders recognized that accessible, high-quality care could not be achieved without exceptional nursing care and leadership (2011). The Institute of Medicine (IOM) in conjunction with the Robert Wood Johnson Foundation (RWJ) convened a committee of experts, the RWJ Future of Nursing Initiative (FON) to determine how nurses, the largest health care workforce in the nation, could be mobilized to implement the goals of these major health care reforms. While acknowledging that nurses have the capacity to fill leading roles in a redesigned health care system, health care leaders recognized that health system inequities prevented nurses from practicing at the level of their professional training and in full partnership with other care providers. The outcome of the IOM FON commission were four key messages yielding eight recommendations that, if implemented, should enable nurses to contribute meaningfully to the improved health of the nation. Embedded in the FON report was the idea that improvements in these key areas would result in better mental health for people throughout the United States.

A decade later, in the backdrop of the World Health Organization's (WHO) International Year of the Nurse and Midwife and a worldwide pandemic caused by the SARS-COV-2 virus, both the systemic weaknesses of the US healthcare system and the vital need for exceptional nursing care are again in sharp focus. The pandemic has exacerbated a pre-existing mental health crisis, highlighting the dire need for psychiatric-mental health nurses (PMH) and other mental health providers (Czeisler et al., 2020). In this environment, a new FON 2020–2030 committee has been empaneled that will evaluate successes in implementing the broad vision of the 2011 FON in the last decade and determine how nurses can better contribute to the rapidly changing health care arena. This special issue of Archives of Psychiatric Nursing includes a collection of 15 professional and data-based papers that address changes in PMH roles and scope of practice, education, and research that have emerged in the last decade and in response to the 2011 FON report, and to make recommendations to the new FON panel. Most of the papers are authored by nationally recognized PMH leaders who provide a unique perspective and lived experience of providing mental health care in the existing health care system. They provide testimony about PMH nurses contribution to quality mental health care and improved outcomes and at the same time, bear witness to the challenges still faced by these practitioners in implementing their unique knowledge and needed skills. The Special Issue provides clear data about achievements relative to each of the four key messages of the 2011 FON report.

The first key message of the FON asserts that nurses should practice to the full extent of their education and training. Several papers provide exemplars of nurses using their knowledge and skills to provide high quality mental health care. These include advanced practice roles in gero-psychiatric and child and adolescent nursing; and at both the advanced practice and the generalist levels, nursing roles that contribute to successful substance use treatment. The emergence of correctional care nursing and nurses' key role in the management of the de Facto mental health system that the prison system often represents, is a clear success in the last decade. A nurse-led effort to mobilize community resources to prevent suicide is described in another paper, an effort that is clearly within the vision of the 2011 FON report. Although the FON report provides little guidance concerning nursing science, there is evidence that psychiatric mental health nursing priority science is being funded by the National Institutes of Health (NIH). The papers illustrate that while PMH nurses' ability to deploy their full scope of practice has been possible within established systems of care, it may be that opportunities for full deployment of nursing knowledge and skills may be more available in non-traditional roles and settings.

Several papers provide convincing evidence that nurse educators have responded to the FON key message that nurses should achieve higher levels of education through an improved education system. Overall, there is evidence of a steady increase in the number of graduate level psychiatric mental health nurse practitioners (PMHNP). One innovative model of doctor of nursing practice education described here, integrated the education of PMHNPs and family nurse practitioners so both groups emerged with expanded physical and mental health skills. Need for and successes in easing the transition from education to practice and their potential as a bridge to advanced practice roles are discussed in other papers in the Special Issue. At the same time, there are notable concerns raised about the direction and methods of PMH education that affect the quality of mental health that can be delivered to specific populations. While diversity was identified as a concern in the FON, research with black PMH nurses showed that these nurses came to PMH nursing haphazardly, and were not mentored into a mental health career. Many papers addressed the elimination of clinical nurse specialist (CNS) education, necessitated by the adoption of the APRN Consensus Model in 2011. A historical and central CNS role is the provision of non-pharmacological interpersonal therapies, embodied in the work of Hildegarde Peplau (1997), and delivered to specific mental health populations like children. Several papers noted that faculty with CNS credentials and expertise in interpersonal therapies are retiring at significant rates, increasing the likelihood that this key role in delivering high quality mental health care will be lost.

The third key message of the FON addressed equity of nurses in partnerships with other professionals. Many of the authors address the invisibility of PMH nurses, and the absence of their voice in advancing high quality mental health care across many roles and settings. Several authors raised concerns about challenges to the full scope of practice of the PMHNPs associated with state level regulatory constraints, dynamics within primary care practice that subjugate PMH nurses, and psychiatrist shortages that require PMHNPs to focus on medication management. With regard to PMH nursing science funded by NIH, principal investigators without PMH background were as likely to lead priority research as those with specific PMH knowledge. Common attributions for inequities evident in several papers were the overall small numbers of PMH and misconceptions about the qualifications and capacity of PMH nurses, especially those implementing advanced practice, educational, or research roles.

The last key message and the eighth recommendation of the 2011 FON was to build an infrastructure for the collection and analysis of workforce data. Indeed, the State Nursing Workforce Centers located in a majority of states are a direct outcome of the FON report. Yet during the two years of collaboration with PMH nurse leaders in the development of this collection of papers, data was frequently part of the conversation. Many of these papers are derived from original research, undertaken specifically to be included in this Special Issue. Identifying sources of existing data and accessibility of that data was a concern of several of these PMH nurse authors. Common too, were data insufficiencies such as lack of specific data in mental health areas of population foci, curriculum content across programs, or for understanding the pipeline of nurse scientists. The papers reveal some critical holes in our understanding of workforce capacities in mental health nursing education, practice and research.

The landmark 2011 FON report provided a road map for ensuring quality health care for the nation generally and has provided direction for PMH nursing. The collection of papers in this Special Issue demonstrates that PMH nurses have clearly advanced their scope of practice and contribution to quality mental health in the decade since the 2011 FON. Still, PMH nurse authors provide a cautionary tale about the work that remains to be done. Even with the increase in the number of PMH advance practice nurses, the authors reveal in their papers that the number is insufficient to fill the gap in needed mental health care, or to provide a strong voice in mental health care system reform. PMH authors describe system and regulatory constraints to achieving equity in partnership with other providers and deploying their full capacity in practice. Data also is sorely needed to determine the need for PMH nurses in practice, education, and research, and to describe the contributions these nurses make, especially as the PMH workforce ages. The collection of papers in this Special Issue provide a clear direction to the 2020–2030 FON as the panel determines how to better support the contribution of nurses to the health needs of the nation. PMH nurses are essential to our nation's public health and require equity in a health care structure that enables them to provide high quality mental health care at their full capacity.