Archives of Psychiatric Nursing
Volume 23, Issue 2 , Pages 91-93, April 2009

A Remembrance and Tribute to the Ideas of Dr Susan McCabe

Department of Community and Mental Health Nursing, Rush University, College of Nursing, Chicago, IL

Article Outline

 

At Archives, we mark the tragic event of Dr Susan McCabe's death with the following remembrance of her scholarly work, particularly Susan's contributions via articles published in this journal. Dr McCabe was a prolific writer, with numerous publications in all of the psychiatric nursing journals and data-based contributions to this journal (McCabe, Macnee, & Anderson, 2001). The focus here will be on Susan's vision of how the psychiatric mental health (PMH) specialty must change if it is to stay vital and of significance to the larger mental health workforce. In three major pieces published in Archives (McCabe, 2000, McCabe, 2002, McCabe and Grover, 1999), Susan spelled out particular challenges the PMH specialty faced. In one sense, we keep Susan's ideas alive by considering how these challenges have or have not been met in the ensuing years and the agenda they set for today.

One theme that treads these three essays is that the profession had failed to adjust to the service delivery environment. When these articles were published in 1999–2000, the effects of managed care on mental health care delivery were already pervasive. Inpatient nurses had witnessed a dramatic reduction in length of stay, and the shift to brief, pharmacological-based treatment was growing. Susan viewed the treatment of patients with mental health issues in primary care as another key marker of change, a dynamic she tied to the neurobiological view of mental illness, patient preference, and the broad dissemination of practice guidelines/information to both patients and primary care providers. Although acknowledging that these factors were partially a result of reimbursement forces, she believed that the shift of psychiatric treatment to primary care signified the specialty's failure to establish professional boundaries and identify the domains of PMH nursing.

Here, Susan builds the argument that this failure to adjust to a changing service delivery environment was also tied to our allegiance to an increasingly outmoded theory base for practice:

Our professional history is coming back to haunt us; making it difficult to articulate the epistemological center of the profession, to clearly articulate our professional uniqueness, to delineate how our scope of practice fits into current care delivery models or to measure in empirical ways the impact of the care practice of psychiatric nurses (McCabe, 2000, p. 110).

In this article, Susan emphasized how the PMH role identity ran contrary to the dominant psychopharmacological treatment model, citing a 1997 workforce survey (Merwin et al., 1997) where advanced practice nurses (APNs) had indicated that their most frequent clinical responsibility was primary therapist. Susan worried that, if PMH nurses' remained peripheral to primary mental health care, tethered to old paradigms of treatment and the theories woven into their traditional role, indeed, the specialty would slowly erode.

Susan saw several factors quickening the erosion of the PMH identity, particularly, the lack of PMH content in undergraduate nursing and the shrinking pool of PMH–APNs. Noting that we were an aging workforce with stagnant numbers of new graduates, she worried about the survival of the PMH–APN workforce. Susan believed that several key issues were hastening the crisis in PMH nursing: titling controversies, the clinical nurse specialist versus nurse practitioner (NP) debate, and the lack of standardization of PMH graduate programs. Emanating from this turmoil was a loss of professional boundaries exemplified by the specialty's failure to identify the domains of PMH nursing and the basic competencies of the workforce. At this point, Susan offered a framework for a new core of PMH–APN training, one built on an array of sciences (i.e., neurobiological, genetics, and immunology) that would be translated to a PMH nursing epistemology around concepts of relatedness, adaptation, regulation, vulnerability, and integrity (McCabe, 2000).

The final component of Susan's agenda for the profession rested with outcome measurement, which she saw as inextricably bound with issues around the epistemological core, professional identification, and competency-based education. “If one does not know what to expect from every psychiatric nurse, it becomes impossible to define the profession, articulate our unique body of knowledge, monitor the quality or the impact of our care” (McCabe, 2000, p. 113). In 2000, there were only scattered publications of PMH nurses' outcomes of care. Susan tied this shortfall in outcomes research to the lack of a PMH research strategy, which in turn reflected the profession's outdated epistemology. She listed an interesting starting point for a PMH research agenda: outcomes, efficacious models, access, nursing service delivery models, care practice for persons with chronic illness, positive dimensions of mental illness, and vulnerability factors. What unified this list of diverse topics was one critical element, that is, the impact of psychiatric nursing on patients' health and well-being, summed up by Susan in the following passage:

We as a profession are fundamentally about understanding human behavior and our roles stem from this function. Within a new paradigm, psychiatric nurses are involved with understanding behavior, assisting patients to understand their behavior, identifying aspects of behavioral change to enhance quality of life, and in assisting patients to make behavioral changes important to their lives (McCabe, 2002, p. 58).

Throughout her writings on strategies to build a new core of PMH epistemology and outcomes, Susan never discounted the role of the relationship in the PMH nursing paradigm, as she so eloquently stated, “It is not an intervention we do as psychiatric nurses…it is the nature of us” (McCabe, 2002).

Seven years past these essays, what progress has the specialty made on the agenda set out by Dr McCabe? It appears that PMH–APNs have moved their practice foci to include prescribing. A recent survey found that close to 70% of APNs prescribe and that more than one third of their work week is spent in prescribing activities alone or in combination with psychotherapy (Drew & Delaney, in press). Since 2002, specific PMH competencies have been developed, and PMH standards of practice have been revised; both are geared to a PMH–APN role in primary mental health care, and both provide a good outline of what the patient might expect from a PMH nurse (American Nurses Association and American Psychiatric Nurses Association, 2007, National Panel for Psychiatric-Mental Health NP Competencies, 2003). As the specialty moves forward, the challenge will be to mesh these competencies with the federal agenda to create a mental health workforce with basic set competencies and an orientation toward consumer-driven, evidence-based care.

The recently revised, Essentials of Psychiatric Mental Health Nursing in the BSN Curriculum (APNA, ISPN 2008) provides a good roadmap for rebuilding PMH content in undergraduate curriculums. The PMH graduate program numbers are on a steady uptick. For many years, PMH nursing had leveled off at slightly below 500 graduates a year. Now, tracking graduates according to American Nurses Credentialing Center (ANCC) certification, for the last 3 years, there were 650 newly certified APNs in the PMH specialty (ANCC, nd). Although titling remains an issue, there are several external factors, particularly the APRN Consensus Group work that may bring the specialty toward a unified role (APRN Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee 2008). The PMH–APN knowledge base is being updated with models where relationship-based approaches are informed by neurobiology and brief therapy models (Wheeler, 2008). A recent article by Parish and Peden (2009) demonstrated that gains have been made in conceptualizing and measuring outcomes of PMH practice.

Unfortunately, in some instances, Dr McCabe's warnings seem to be ringing true. Psychiatric nursing continues to be virtually invisible in federal plans for transformation of the mental health workforce, and nurses are rarely seen on the roosters of federal mental health task forces (Delaney, 2008). Although neurobiology is slowly being woven into PMH nursing texts, the review books for PMH nursing certification examinations are organized around traditional knowledge blocks, not significantly updated by recovery, evidence-based practices, or trauma-informed care. The acrimony generated by the APN title and role change persists, particularly in evidence at meetings of PMH professional organizations. Finally, the lack of standardization in PMH graduate curriculums continues; a recent survey of PMH programs found 86 different texts in use, with the majority authored by psychologists and psychiatrists (Wheeler & Delaney, 2008).

In her last editorial for Archives, Dr McCabe (2006) emphasized the vital role of professional organizations in addressing the dilemmas the specialty faced. She urged all nurses to join and become active in crafting solutions. Indeed, as we consider gains, challenges, and opportunities, the role of professional organizations clarifies. The future lies with partnerships, collective action, and strategic connections. For instance, instead of expecting individual practitioners to be the primary source of outcome studies, APNs may need to partner with researchers skilled at mining encounter data and also join in national practice/quality surveys. As we develop PMH research agenda, the specialty might look to the strategies developed in the international PMH community and find avenues for engaging in collaborative investigations of PMH interventions. The festering arguments around titling should be replaced with a plan for connecting the PMH educational vision with federal workforce agenda, aiming to create a PMH workforce uniquely trained to address gaps in mental health service delivery. One critical strategic connection is within our own workforce. We must connect the agenda of PMH nurses in hospitals and community with the agenda of the PMH–APN workforce. The impact of PMH practice will come from this collective of psychiatric nurses, working to integrate evidence-based practices into all the care sites where they practice. As we move toward these challenges and opportunities, the specialty will miss Dr Susan McCabe's intellect and vision. We are fortunate to have her writings which provide a deep keel for the future direction of the specialty.

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References 

  1. Advanced Practice Registered Nurse (APRN) Consensus Work Group and the National Council of State Boards of Nursing APRN Advisory Committee. Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved on February 1, 2009 from http://www.aacn.nche.edu/Education/pdf/APRNReport.pdf2008;
  2. American Nurses Association , American Psychiatric Nurses Association  International Society of Psychiatric Nurses. Psychiatric–Mental health nursing: Scope and standards of practice. Washington, DC: ANA, APNA, ISPN; 2007;
  3. American Nurses Credentialing Center (ANCC) . Certification statistics. Retrieved on January 30, 2009 from http://www.nursecredentialing.org/Certification/PoliciesServices/Statistics.aspx
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PII: S0883-9417(09)00021-1

doi:10.1016/j.apnu.2009.02.002

Archives of Psychiatric Nursing
Volume 23, Issue 2 , Pages 91-93, April 2009

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