Nursing Archive

The national Mental health center

ADVANCED PRACTICE registered nurses (APRNs) with prescriptive practice in Psychiatric Mental Health Nursing are being challenged to demonstrate the clinical and economic value of their role. Policymakers, insurers, employers, and society at large expect accountability for practice that is supported through data-based evaluations [Barrell et al 1997]. According to [Pearson 1999], more than 100 studies have documented the competencies of NPs and substantiated the ability of NPs to deliver safe care. However, there is a dearth of similar research in the area of psychiatric APRNs’ prescriptive practices. Nationally, the incidence of having a severe mental disorder is 2.8%, and those with a severe mental disorder using mental health services is 1.8% according to the National Comorbidity Study [Kessler et al 1994. R.C. Kessler, K.A.M. Gonagle, S. Zhao, C.B. Nelson, M. Hughes, S. Eshleman, H.U. Wittchen and K.S. Kendler, Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Archives of General Psychiatry 51 (1994), pp. 8–19. View Record in Scopus | Cited By in Scopus (5515)Kessler et al 1994]. Psychiatric APRNs contribute to increased access to services for people in need of mental health treatment. This exploratory study identified and described variables in APRN and psychiatrist prescriptive practice patterns. The cooperative practices of the prescribing professionals (APRNs and psychiatrists) in this study function as a progressive model of care that operates with harmony and mutual respect. The sharing of cases between prescribers in this study can be seen as a statement about the flexibility of the treatment available to clients and the fluidity with which continuity of care was sustained within the mental health center. Administrative support and the APRNs’ record of effective caseload management have been factors in acceptance of the APRN role of prescriptive practice at the agency and in the community.

The Utah Nurse Practice Act grants independent prescriptive authority to psychiatric nurses with advanced practice licensure and certification after they have completed a 2-year internship. They must have a master’s degree in psychiatric mental health nursing, including courses in health assessment and psychopharmacology. In 1996 the Prescriptive Practice Board voted to support a revision of the Utah Nurse Practice Act that would discontinue the consultation and referral plan in favor of a quality peer review program for APRN license renewal. Physician collaboration is required only for APRNs prescribing Schedule II–III controlled substances. APRNs prescribing Schedule IV–V controlled substances do not require physician collaboration.

Research questions

Research Question One:What are the similarities and differences in clients for whom APRNs and psychiatrists prescribe?

Research Question Two: What are the similarities and differences in the types and numbers of medications prescribed by psychiatrists and APRNs?

Two diagnoses, chronic paranoid schizophrenia and recurrent major depression, were selected for Research question two. The National Alliance for the Mentally Ill included these two diagnoses in their criteria for severe and persistent mental illness. These two diagnoses were identified by the World Health Organization as being among the 10 leading causes of disability in the world, and they were included in those illnesses with the highest burden of care [American Nurses Association (ANA].

Chronic paranoid schizophrenia and recurrent major depression were selected to allow for comparison of professional groups’ prescribing practices while controlling for variance in the population served. These diagnoses occurred with enough frequency to ensure that sufficient numbers of cases were available for review, and both diagnoses generally included medication management in the treatment of the illness. In this study, clients might have had more than one diagnosis for comorbid conditions. Clients might have had treatment-resistant illnesses that were often managed with combinations of medications within the same class and/or from different classes. For example, an individual with recurrent major depression with psychotic features could conceivably have been treated with an antidepressant, a mood stabilizer, an antipsychotic, and an antianxiety medication.

Methodology

This study was part of a larger study comparing physicians’ and APRNs’ prescriptive practices with people who have severe psychiatric illnesses. This study answered the first two quantitative research questions. The third question was a qualitative question regarding APRN and psychiatrist perceptions of their practices and is reported separately.

Setting

A large public mental health center located in a western state was the setting for this study. The geographic area served by the agency encompasses one urban and two rural counties with a total population of 913,736 [United States Census Bureau 1999]. Services for a full continuum of care are provided for adults, children, and adolescents.

Human subjects protection

Approval for this study was obtained from the University of Utah and from the Department of Human Services of the State of Utah.

Research question one: what are the similarities and differences in the clients for whom APRNs and psychiatrists prescribe?

Sample

For question one, the sample of adults receiving treatment in the year 2000 was drawn from the database of a large public mental health center. Client demographic variables and every client service contact were coded using standard categories and entered into the mental health center’s database by the agency Management of Information Systems (MIS). Guidelines for systems of data collection are available through the NIMH Information Systems Series, FN No. 10 (MHSIP), Data Standards for Mental Health Decision Support Systems (1989). Categories of data used at the mental health center in this study were defined in standardized terms by MHSIP [National Institute of Mental Health (NIMH].

During the study timeframe, 422,438 service contacts were recorded for 7,251 adult mental health clients. Of the 7,251 adults, 5,507 (76%) were coded as having had a medication evaluation and/or medication management contact with an APRN or a psychiatrist. Because a service contact is coded each time a client was seen at any site (for example, inpatient, residential, outpatient, and so on), it was possible for a client to have contacts coded for both an APRN and a psychiatrist at different times during the year. Of the 5,507 adult clients, 1,589 clients were treated only by an APRN, 3,293 clients were treated only by a psychiatrist, and 625 clients were treated by both an APRN and a psychiatrist, but at different times during the year.

Tags: mental health