The psychiatric mental health nurse practitioner in the general practice: a realist evaluation multiple case study

Mental health problems are highly prevalent worldwide and the mental health system faces significant gaps in treatment coverage due to stigma, professional shortages and accessibility issues. In the Netherlands, patients first visit their general practitioner (GP) for mental health problems, with an increasing number of people seeking mental health counselling and treatment in general practice. Dutch general practices have been experimenting with deploying psychiatric mental health nurse practitioners (PMHNP) to enhance mental healthcare accessibility. How to best deploy this profession in the general practice team and everyday care, is yet unknown.

This study aims to understand how deployment of the PMHNP in the general practice works and how it contributes to the accessibility and quality of mental primary healthcare and job satisfaction of professionals in the general practice.

This multiple case study used principles of realist evaluation methodology for data collection and analysis focusing on context, mechanism and outcome (CMO). Seven general practices employing a PMHNP, were included. Data was collected through observations, interviews and group discussions with professionals working in the general practice and patients treated by the PMHNP. Cross-case analysis involved work sessions with professionals of these seven cases.

This study identified three mechanisms that provide insight into how deploying PMHNP contributes to improved experienced accessibility and quality of mental health care, enhances job satisfaction and reduces workload especially for the GP: (1) motivation and investment; (2) familiarity and trust; and (3) equivalence and autonomy. These mechanisms were triggered in a context with the presence of (1) a vision on mental health care in general practice, (2) physical attendance of the PMHNP, (3) a patient population suited to the expertise of the PMHNP, and (4) financial possibilities.

Participants in this study believe a transition in general practices is necessary to provide sustainable, lowtreshold mental healthcare in primary care setting. They see the PMHNP as the professional to fill this gap. To optimally deploy the PMHNP and ensure accessible, high-quality mental healthcare, the mechanisms of (1) motivation and investment, (2) familiarity and trust, and (3) equivalence and autonomy should be activated.