In hiring a new NP or PA, it is important to recognize that there is a significant difference in the amount of psychiatric training that each of these providers has experienced. Psychiatric NPs receive more psychiatric training than a PA, who may have as little as a single rotation in a psychiatric setting and a few weeks of lectures. Of course, this difference in training may matter less if one is hiring an NP or PA with several years of psychiatric experience.

In hiring an NP or PA who is straight out of training, one must realize that there is a significant investment of time to mentor the new hire. Before hiring a recently graduated NP/PA, our system recommends speaking to the supervisor and staff of the section/department in which the NP/PA will be working and informing them that a recent NP/PA graduate is being considered for their department. The expectation is that the new NP/PA will require both teaching in the form of didactics, but also in everyday supervision and mentorship during the clinical day. Make sure that the staff is willing and capable of providing an education to the new NP/PA before hiring.

Our system has embarked on a unique method of training psychiatry NPs and PAs with the establishment of a Psychiatry Advanced Clinical Practitioner (ACP) Fellowship. This is a year-long period of supplemental training for psychiatric NPs and for PAs who want additional intensive specialization training in psychiatry. Our ACP fellows have 16-week rotations on inpatient psychiatry, outpatient psychiatry, ED psychiatry, and consult liaison psychiatry. Additionally, they receive weekly didactics/presentations on major psychiatric topics. Case presentations and journal club are also a part of their regular didactics. Supervision goes beyond the requirements for formal supervision. In our view at our system, supervision is a daily activity. The NP/PA must be able to access his/her supervising psychiatrist in order to staff cases or ask questions. This means that the supervising psychiatrist must be readily available, either in person on via telephone/teleconference.

As a child and adolescent psychiatrist working as a medical director for a rural community agency that serves children and adolescents, I was asked to serve as a preceptor for a student NP. During the 6 month preceptorship, the student NP shadowed me observing all clinical activities. After a period of approximately one month, I observed the NP student performing different aspects of clinical work. Patients were discussed in detail with regular feedback on NP student’s performance. Once I felt the student was ready, the NP began seeing patients individually, with an oral presentation, and then patients were seen jointly by myself and the student.

After the completion of the preceptorship and subsequent graduation, the NP was hired to help develop outpatient psychiatric services for the agency. The Psychiatric Nurse Practitioner (PNP) and I met weekly on a formal basis and I continued to be available for informal consultation in person and by phone. I also assisted the PNP in developing relationships with other community providers (pediatricians, therapists, etc.). In addition, the PNP participated in weekly clinical staff meetings that included formal lectures, clinical reviews, and oral/video case presentations.

Four years later, the PNP is the primary clinician for the outpatient psychiatric services serving many children and adolescents in this rural area. I continue to have monthly formal meetings with the PNP and continue to be available by phone for consultation. The formal meetings between us include discussions of specific topics identified by either party as areas of improvement along with presentations of complex cases. In our rural setting and with an NP who is a recent graduate, providing this level of supervision gives both of us peace of mind as she practices in such a remote location.

In general, introduction of a NP/PA to any psychiatric practice depends on several variable factors such as whether he/she is freshly graduated from school, he/she has had other medical experience and is transferring to the psychiatric field, he/she has graduated from an accredited psychiatric training program, or he/she is an experienced and accredited psychiatric PA or NP who is moving to the practice. For example, I supervise three NPs and two PAs who have varying degrees of on-the-job training in our setting. The integration, training, and supervision are significantly different between outpatient, consult/liaison (C/L), and inpatient settings. All training should be specifically individualized between the supervisor and supervisee.

In an Inpatient setting, it is our practice for the NP/PA to shadow the psychiatrist for the first month, observing the interview, eliciting information, developing a differential diagnosis and initiating a specific treatment plan including appropriate polypharmacy. The NP/PA will perform ancillary services and begin to write follow-up notes. Gradually, depending on the level of achievement, the NP/PA will conduct the intake interview in the presence of the attending and discuss his/her thoughts on the initial diagnosis and treatment. At the end of the six months, the NP/PA should be competent to conduct a psychiatric interview and implement the recommendation of the attending. All dictated notes and charting should be co-signed for the first six months. After six months, co-signing the charting is optional, depending on the bylaws of the hospital.

In C/L services, the NP/PA should follow the psychiatrist for at least one month to observe the variety of consults. During this time, the psychiatrist will interview, formulate a diagnosis and initiate a treatment plan. The NP/PA should be given ample opportunities to observe the documentation process and charting by the psychiatrist. The NP/PA may see the patient for the follow up, discuss the adjustment of medications and write a note. Between 3 to 6 months, the NP/PA may start seeing uncomplicated consults, report the findings, formulate a diagnosis and suggest a treatment plan with the psychiatrists either in person, via telepsychiatry, or by telephone. The NP/PA can document the consult findings in the chart on behalf of the attending. After six months, he/she may perform uncomplicated consults independently and if needed, discuss the case with the attending. In my experience, for the first six months, every consult should be co-signed by the attending. After six months depending on the bylaws of the hospital, co-signing can be optional.

Regardless of the frequency of supervision as described in the prior examples, the quality of the supervision time is important. Many psychiatrists find it easier to structure this time.

The Suggested Checklist for Supervision and Quality Improvement Meeting Form are documents a psychiatrist could use to organize the supervision meeting and document it for the file.

The Suggested Checklist for Supervision is a template checklist that identifies which documents must be on site and in the file according to NCMB and NCBON standards, should you be audited. It also serves as a concrete vehicle for following up from previous sessions and noting improvements from a Quality Improvement perspective. This not only helps document supervision, but it is a useful tool for discussion that should serve to improve care that is delivered by both of the professionals. Topics or concerns that should be addressed include ethical issues, administration concerns or future topics for Quality Improvement.

Part of supervision is also being able to make recommendations for additional education when the need or opportunity arises. You might attend a local or national meeting together. Other suggestions include:

1. AudioDigest Psychiatry
2. NCPA Annual Meeting
3. Lifelong Learning Modules thru AACAP
4. Focus: The Journal of Lifelong Learning in Psychiatry (APA)
5. Journal reviews
6. Risk management courses
7. Ethics courses
8. Psychiatric Drug Alert; Child & Adolescent Psychiatric Alert and Psychiatric Alert NOS monthly publications

Below are examples of different elements of practice that can be included in a quality monitoring program. These elements can be reviewed by the psychiatrist through a record review or other means and serve as a measure of the quality of care that the NP/PA is providing. Through this, opportunities for training and education can be identified. This list is not meant to be exhaustive.

1. Monitoring of metabolic syndrome with antipsychotics
2. Management of depression, psychotic disorders, anxiety, and bipolar disorders
3. Documentation of substance use history and referral to substance abuse treatment
4. Documentation on nutrition education
5. Screening for substance use disorders
6. Documentation of trauma history
7. Justification for the use of two or more antipsychotics.
8. Suicide/homicide risk assessment
9. Clozapine CBC monitoring
10. Appointment No Shows