Date of Award

Spring 2026

Project Type

Clinical Doctorate

College or School

CHHS

Department

Nursing

Program or Major

DNP

Degree Name

Other

First Advisor

Kerry Nolte

Second Advisor

Amy Manning

Third Advisor

Cathleen Colleran

Abstract

Abstract

Title: Enhancing Psychiatric Education and Training for Family Nurse Practitioners in Rural Health Settings

Background: Mental health conditions represent a significant and growing proportion of primary care encounters, particularly in rural and underserved regions where psychiatric specialist access remains critically limited. In these settings, Family Nurse Practitioners (FNPs) frequently serve as the sole point of contact for patients presenting with mental health concerns, often without the benefit of embedded behavioral health support or readily available consultation. Despite carrying this clinical responsibility, many FNPs report gaps in formal psychiatric training, particularly in psychopharmacology and diagnostic differentiation, that contribute to variability in provider confidence, prescribing practices, and independent management of psychiatric conditions. These gaps have direct implications for the quality and timeliness of mental health care delivered in rural primary care settings.

Purpose: This quality improvement project aimed to evaluate the effectiveness of a structured psychiatric education and case-based consultation intervention in improving provider confidence and influencing clinical practice behaviors among FNPs in a rural Federally Qualified Health Center. A secondary aim was to assess whether improvements in provider confidence corresponded with measurable changes in clinical behavior, including prescribing practices, diagnostic recognition, and referral decision making.

Methods: A pre-post intervention design was implemented at Missouri Highlands Healthcare, a rural Federally Qualified Health Center in Southeast Missouri. Nine FNPs completed a 10-week intervention structured in two phases: four weeks of self-paced, asynchronous psychiatric education modules followed by four weeks of weekly case-based consultation sessions lasting 45 to 60 minutes. Educational content was organized around four high-prevalence psychiatric conditions in primary care: depressive disorders, anxiety disorders, bipolar disorder, and psychotic disorders, with integrated emphasis on psychopharmacologic management throughout. Provider confidence was assessed using a five-domain Likert-scale survey administered at baseline and post-intervention. Clinical practice behaviors were captured through a standardized 30-day retrospective self-report tool evaluating patient volume, diagnostic recognition, medication initiation and titration, referral patterns, and provider-reported avoidance of psychiatric management. Data were analyzed using descriptive statistics and pre-post comparisons, with emphasis on clinical significance given the small sample size

Intervention: The intervention was built around two complementary components. Structured psychiatric education was delivered through the Sarah Michelle PMHNP Review program, covering core diagnostic and pharmacologic content across four clinical domains. Case-based consultation sessions followed, during which providers applied newly acquired knowledge to real patient cases drawn from their own practices. Weekly discussions were facilitated by the project lead and emphasized diagnostic reasoning, psychopharmacologic decision making, and evidence-based clinical management within the context of rural primary care. This sequenced approach was grounded in the Diffusion of Innovation framework, progressing providers from knowledge acquisition through implementation and confirmation of practice change.

Results: Improvements were observed across all measured domains of provider confidence, with mean confidence scores increasing from 2.6 to 2.8 and median confidence scores improving from 2.0 to 3.0. Providers demonstrated increased engagement in psychiatric care, including higher rates of medication initiation and titration and improved recognition of depressive, anxiety-related, and mood disorders. Referrals driven by lack of confidence decreased, with a shift toward lower-frequency referral patterns, including an increase in providers reporting 0 to 2 referrals (44% to 89%) and a reduction in higher referral categories. Additionally, providers reported reduced avoidance of managing psychiatric conditions due to low confidence and expanded utilization of psychotropic medication classes in clinical practice. While statistical significance was limited by sample size, trends indicate clinically meaningful improvement.

Conclusion: A structured psychiatric education program combined with case-based consultation is a feasible, low-barrier, and clinically meaningful approach to improving provider confidence and practice behaviors among FNPs in rural primary care. Critically, improvements extended beyond self-reported confidence and were reflected in observable changes in clinical behavior, supporting the effectiveness of this model as a quality improvement strategy. Strengthening the psychiatric capabilities of rural primary care providers has broad implications for reducing delays in mental health treatment, decreasing unnecessary specialty referrals, and improving access to evidence-based psychiatric care in communities where it is needed most. This model warrants consideration for integration into ongoing continuing education frameworks and organizational onboarding programs in rural healthcare settings.

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