Nursing Archive

Nurse Practitioner And Mental Health

Historical contextThedecade of the s was remarkable for the pace and magnitude of changein health care and information technologies, neuroscience, healtheconomics, and health policy. Among the many such changes affectingadvanced practice psychiatric nursing included the explosion of newknowledge about the biological bases of mental illnesses; thedizzying pace of health care reform, including relegation of its formand structure to the marketplace; the shift to primary care as asingle point of entry for comprehensive health care services, includingspecialty care like psychiatry; confusion about the degree to whichprimary care includes and is included in primary mental health care; the debate within nursing about the future of advanced practice,particularly whether to merge clinical nurse specialist CNS and nursepractitioner NP roles and,and the related debate within psychiatric nursing about whether toprepare the advanced practice psychiatric nurse APPN of the future asCNS, NP or some blend of both and.Thedebate in psychiatric nursing was essentially about how to control itsown destinyâ??how to define its future, manage the direction of changeand still keep faith with the public while responding appropriately toshifting individual, community and regional needs. Fundamentally, itwas a debate between competing visions of what psychiatric nursing isand should be.It coalesced around issues of role, scope of practice, educationalpreparation, titling, and credentialing for the APPN identified as aPMHNP. Unfortunately, albeit understandably when practitionersâ??identities, legitimacy and turf are perceived to be at stake, thetitling issue became a flashpoint. The controversy became particularlyheated as new educational programs for highly diverse psychiatricnurse practitioner roles appeared in the nursing literature and, the scope of practice and credentialing requirements for the manyvarieties of psychiatric nurse practitioner became more confusing and ANCC proceeded with development of a national certifyingexamination for the new role â??before the dust of innovationâ? hadsettled , p.. Clearly, psychiatric nursing was not opting for a titling changeso much as it was being drawn somewhat chaotically towards one â??on thelogic of market forces, population needs, state regulations, and thescience of treatmentâ? , p..Thebackground for the CNS versus NP controversy, the historicaldevelopment of the role of the psychiatric nurse practitioner and adescription of the market forces, community needs, regulatoryprocesses, and technologic and scientific developments that influencedthe development of the role are richly detailed in the literaturealready cited, as well as elsewhere and.Rather than revisit those issues, this article proposes to identify thecontroversies that linger in the wake of the now-existing ANCC PMHNPcertification examinations adult and family, whose content outlinesclearly identify the professional standards and scope of practicerelevant to the certified role. These are the Scope and Standards of Psychiatric-Mental Health Nursing PracticeAmerican Nurses Association [ANA], American Psychiatric NursesAssociation [APNA], and International Society of Psychiatric-MentalHealth Nurses [ISPN], and the Scope and Standards of Advanced Practice Registered Nursing.This clear articulation of the scope of practice of the APPN, whetherprepared as CNS or NP, may finally put to rest much of the controversyaround the role definition of the so-called psychiatric nursepractitioner. The credentialing examinations, in turn, may finallylegitimize a role that, like it or not, has existed with multiplevariations since.The titling issue may continue to bethorny, and it is conceivable that at some point in the future thepsychiatric nurse practitioner and the psychiatric clinical nursespecialist with prescriptive privilegesâ??whose roles have considerableoverlapâ??might share a single, perhaps new APPN title. However, themultiple roles of the psychiatric nurse practitioner are not going togo away, based as they are on irreversible changes in the science ofcare and on community and regional needs. The certificationexaminations may finally lend some consistency to currentconceptualizations of the role and place a precedent for practicerequirements at a national licensing and certification level, which iscertainly the level at which they belong, as well as place somemuch-needed boundaries around a nebulous role that heretofore has beenregulated only at the state levelâ??and not in all states.At the very least, nursing and its public may finally reach consensusabout who this new clinician is, what he or she does, how he or she isprepared for practice and what kind of additional educationalpreparation, competencies, and credentials are required either tofurther expand the role in response to various regional needs or toaccommodate the multiple, already-existing, expanded role variants.Controversial as development of the psychiatric nurse practitionerexams has been, by articulating that the professional standards towhich ANCC-certified psychiatric nurse practitioners adhere is therevised Scope and Standards of Psychiatric-Mental Health Nursing Practice,ANCC may have saved advanced practice psychiatric nursing forpsychiatric nurses. That is, it has reinforced in a very concrete waythat the scope of practice, standards and competencies exercised bythose who identify themselves and seek credentialing as psychiatricnurse practitioners will continue to be defined by psychiatric nursesand their professional organizations, as opposed to other advancedpractice nurses e.g., adult and family nurse practitioners whoprovide to diverse populations not only primary care, butalsoâ??increasinglyâ??a limited range of psychiatric services.The varieties of PMHNP educational preparationThe psychiatric nursing literature to date describes several models for educational preparation of the PMHNP and. detailed the Psychiatric-Primary Care Nurse Practitioner PPCNPprogram at the University of Pittsburgh, which prepared its graduatesfor a role that combined primary care and psychiatric-mental healthclinical competencies. In those graduates were educationallyprepared to â??plan, implement, and evaluate therapeutic regimens forpatients with common acute and chronic health needs and problems aswell as common and complex psychiatric needs and problems, includingboth nursing and medical strategies â?¦.â? p.. The PPCNP thusprepared sat for the American Academy of Nurse Practitioners AANPcertification examination for the Adult Nurse Practitioner ANP. It isnot clear whether it was intended that future graduates would sit for anew national certification examination for the psychiatric nursepractitioner instead of the ANP certification examination or inaddition to it. With the advent of the ANCC PMHNP certificationexamination, it is now evident that those graduates, if they intend toexercise both sets of competencies, will need to sit for both.described the approach used to prepare nurses for a blended as opposedto combined role in psychiatric-mental health nursing at theUniversity of South Carolina College of Nursing. They cited some of thenow well established evidence that psychiatric problems areunderdiagnosed and undertreated by family physicians and adult/familynurse practitioners in primary care settings. Their graduates, referredto as â??mental health practitioners/specialistsâ? were prepared toprovide more appropriate primary mental health care and referral tovulnerable and underserved populations who would continue to needmental health care in any type of reformed health care system. Theseclients required nurses who could â??assess both physical and emotionaldimensions of symptoms, treat common physical problems, and makeappropriate referral for more complex problemsâ? p.. Although thisvision conforms closely to the â??blended roleâ? described in the Scope and Standards of Psychiatric-Mental Health Nursing Practice,the investigators explicitly stated that the intention of their programwas to prepare graduates for certification as both ANP and PMHCNS. Withthe availability of the ANCC adult PMHNP examination, it is not clearwhether this intention has held. Clearly, if such graduates plan topractice primary care with psychiatric populations unrelated to theirpsychiatric diagnoses and/or psychopharmacologic management, they, too,in accordance with the Scope and Standards of Psychiatric-Mental Health Nursing Practice will need to continue to obtain dual certifications. responded to and described the curriculum at Kent State University School ofNursing, which â??prepares the traditional psychiatric CNS with anadd-on year of preparation in adult primary care that is specificallytailored to meet the physical needs of the psychiatric populationâ? p.. They viewed their program as complementary but different from thePPCNP program at the University of Pittsburgh, which was seen asâ??primarily a nurse practitioner role with specialized education formeeting the primary care needs of a psychiatric populationâ? p..Their graduates were considered primarily psychiatric CNSâ??s who hadadditional specialized education in primary care that allowed them toscreen and manage physical illnesses as they manifested in psychiatricpatients. Those graduates would sit for the ANCC adult PMHNPexamination when it became available.The vision at the University of Washington School of Nursing was similar.Their educational program prepared the Psychosocial Nurse PractitionerPSNP in an expanded APPN role to deliver primary mental health careto complex psychiatric populations who had comorbid psychiatric,substance use and physical disorders. PSNP competencies were entirelycongruent with those described in the Scope and Standards for Psychiatric-Mental Health Nursing Practiceand included skills in biopsychosocial assessment, developmentalassessment, environmental e.g., family assessment, differentialdiagnosis of psychiatric and comorbid medical conditions, healthhistory, screening physical examination, use of pertinent laboratorystudies, and psychopharmacology. In their graduates were certifiedas psychiatric-mental health clinical nurse specialists and wereexpected to be eligible for the ANCC adult PMHNP exam when it becameavailable. Interestingly, the program at the University of Washingtonconsidered and rejected preparation of graduates within the existingmasterâ??s program for an additional certification as either adult orpediatric nurse practitioner. They wanted to keep the length of theprogram manageable and retain its emphasis on mental health. Studentswho wanted to further expand their role could prepare for anothercertification in a postmasterâ??s program.Finally, described the comprehensive program at Yale School of Nursing, whichincluded PMHCNS, PMHNP and postmasterâ??s PMHCNS options. PMHNP graduateswere dually prepared to sit for certifications in both adult primarycare and a psychiatric clinical specialty in accordance with the beliefthat there â??should be one examination to evaluate competencies in thearea of psychiatric nursing principles and skills and a separateexamination to evaluate competencies in adult primary careâ? p..The belief in separate competencies for the two nursing specialty areasis consistent with the Scope and Standards of Psychiatric-Mental Health Nursing Practice.It would seem Yale School of Nursing PMHNP graduates are eligible tosit for the ANCC PMHNP examinations as well as the ANP examination. Ofnote, the Yale faculty expressed their strong belief that there is aneed in the psychiatric-mental health discipline for both the PMHCNSand PMHNP roles. echoed their belief in her description of the psychiatric CNS programat Catholic University. She articulated the view that there is a vitalrole for the PMHCNS with prescriptive authority in meeting the needs ofunderserved psychiatric populations in community settings.

Tags: mental health, nurse practitioner