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Change to State Law Necessary to Retain APRNs, Address Mental Health Workforce Shortage

By: Justin Cullers, APRN, PMHNP-BC



In the wake of COVID and other world events, many of us are struggling emotionally, meaning the need for accessible, affordable mental health care is ever increasing. For Texans, accessing that care is its own struggle, particularly in rural areas, with 97% of Texas counties federally designated as Mental Health Professional Shortage Areas.


Fortunately, there is a talented workforce ready to deliver these desperately needed services in the form of psychiatric-mental health nurse practitioners, or PMHNPs. These clinicians complete rigorous training and are board-certified in their specialty. Patient, meet your psych NP. Psych NP, meet patient. Problem solved!


If only it were that simple.


Unfortunately, the state of Texas clings to outdated regulations that prevent psychiatric-mental health nurse practitioners and all other Advanced Practice Registered Nurses (APRNs) from practicing to the full extent of their education, licensure, and certification. And so, APRNs are leaving our state to work elsewhere, and for good reason.


Job security for APRNs is fragile. To work in Texas, all APRNs must find a physician willing to enter into an ongoing, yearly delegation agreement, often at a cost of thousands of dollars a month. Finding a delegating physician is remarkably challenging, particularly in rural areas with dire provider shortages. Delegation requirements are never-ending, but the supply of willing physicians is not. According to a 2022 member survey by Texas Nurse Practitioners (TNP), nearly 31% of Texas nurse practitioners reported their delegating physician was planning to retire within the next two years. If a delegating physician stops practicing for any reason, the APRN must immediately stop too. The result? Hundreds of people instantly lose access to care.


Thankfully, Senator César Blanco has introduced the HEAL Texans Act, SB 1700, which will eliminate the need for delegation agreements to free APRNs to provide the same scope of care they already do, only without these costly contracts.


Over half of all states and numerous federal organizations—from the U.S. Department of Veterans Affairs to all military branches—have already done away with delegation requirements. Our loss is their gain. Take New Mexico, for example. Since the state dropped its delegation requirement a decade ago, a steady stream of quality APRN talent has been drained from El Paso and across West Texas.


New Mexico is not the only willing recipient. The rapid expansion of telemedicine has accelerated the Exodus to APRN-friendly states. Log in, and through the magic of technology, an APRN can work anywhere.


I have been a psychiatric-mental health nurse practitioner for nearly a decade. Over the last two years, I have run a support group for first-year graduates.. Thus far, every new psychiatric-mental health nurse practitioner resided in a Mental Health Professional Shortage Area, and all of them reported barriers making it more difficult to practice in their region. This is particularly sad as most of them started their graduate programs with the intent of serving their local communities. For example, one new UT-Tyler graduate very much wanted to practice in the Tyler area. After months of fruitlessly searching for a delegating physician in East Texas, she ended up taking a telemedicine position providing psychiatric care in New York.


Seasoned APRNs of all specialties are also considering leaving Texas. According to the Texas Nurse Practitioners 2022 Member Survey, 71% of NPs would consider practicing telemedicine across state lines and 51% would consider moving to another state to practice. This includes family nurse practitioners, who are the largest block of NPs and the workhorses of many primary care clinics across Texas.


This trend is reversible, and the solution is clear. Florida, New York, and California have recently passed legislation to eliminate unnecessary mandates on APRNs and now allow them to practice to the full extent of their education and experience. These states are benefiting from increased APRN resources, including those from Texas. Making the HEAL Texans Act law will help retain and bring our APRNs back home, where they belong: serving Texans.


Justin Cullers, APRN, PMHNP-BC, is a Texas psychiatric mental health nurse practitioner and a representative on the board of the Psychiatric Advanced Practice Nurses of Texas.

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