Advertisement

The Evolution of the Role of the Psychiatric Mental Health Advanced Practice Registered Nurse in the United States

      Abstract

      I recently met with an undergraduate nursing student who was interested in psychiatric mental health (PMH) nursing. She specifically wanted to know about the role of the PMH advanced practice registered nurse (APRN). That conversation took considerably more time than it might have taken in 1987 when Dr. McBride and her colleagues evaluated the effect of a PMH clinical nurse specialist (CNS) on nursing communication and work environment in a state psychiatric hospital (
      • McBride A.B.
      • Austin J.K.
      • Chesnut E.E.
      • Main C.S.
      • Richards B.S.
      • Roy B.A.
      Evaluation of the impact of the clinical nurse specialist in a state psychiatric hospital.
      ). A great deal has changed since that time with regard to advanced psychiatric nursing practice and the mental health care environment. PMH advanced practice registered nursing (APRN) has evolved to fill a variety of niches as mental health care delivery has been transitioning away from traditional hospital-based care. The purpose of this paper, then, is to explore the changes in the role of the PMH APRN in the U.S. that have occurred since the first issue of Archives of Psychiatric Nursing was published in 1987.

      The primary roles: clinical nurse specialist and nurse practitioner

      The PMH CNS was the first master's prepared advanced practice nurse of any specialty; a role shaped by Hildegard Peplau as she developed the graduate program at Rutgers University in 1954 (
      • Rust J.E.
      Dr. Hildegard Peplau.
      ). Under Peplau's direction, the emphasis of the CNS graduate program grew to focus on the development of skills in psychotherapy (
      • Spray S.L.
      The evolution of the clinical nurse specialist: An interview with Hildegard E. Peplau.
      ). Competencies also included organizational analysis and consultation service—a systems understanding of nursing, healthcare delivery and the change process (A. W. O'Toole, personal communication, March 3, 2014). PMH CNSs, then, also provide consultation and liaison services and support and education for nurses, other healthcare providers, families and patients. These were the primary CNS tasks that were evaluated by
      • McBride A.B.
      • Austin J.K.
      • Chesnut E.E.
      • Main C.S.
      • Richards B.S.
      • Roy B.A.
      Evaluation of the impact of the clinical nurse specialist in a state psychiatric hospital.
      . Graduates from Rutgers, and programs that were later developed, assumed positions in hospitals, community mental health centers, and private practice. CNSs were certified to provide services to adults and, later, to children and adolescents.
      The PMH NP role was introduced in the early 1990s and legitimized with the development and availability of a certification exam for adult and family PMH NPs in 2001 by the American Nurses Credentialing Center (ANCC;
      • Bjorklund P.
      The certified psychiatric nurse practitioner: Advanced practice psychiatric nursing reclaimed.
      ). The role was designed to address multiple forces in the healthcare environment including a substantial body of research that demonstrated the relationship between neurobiologic processes and mental illness and growing recognition of the need for primary mental health services and mental illness prevention (
      • Delaney K.R.
      The psychiatric nurse practitioner 1993–2003: A decade that unsettled a specialty.
      ). Therefore, the knowledge and skills needed for both physical and mental health assessment were considered critical. While initially there was variation in educational preparation for PMH NPs, competencies developed by the
      • National Panel for Psychiatric-Mental Health NP Competencies
      Psychiatric–mental health nurse practitioner competencies.
      helped to standardize curricula, to some degree (
      • Delaney K.R.
      The psychiatric nurse practitioner 1993–2003: A decade that unsettled a specialty.
      ).
      The development and growth of the PMH NP role did not create a happy situation for many PMH CNSs as evidenced by heated exchanges at professional meetings and published commentary (see
      • Delaney K.R.
      The psychiatric nurse practitioner 1993–2003: A decade that unsettled a specialty.
      for an excellent review). The rate of certification of PMH NPs was on the rise as the number of PMH CNS certification applicants was declining (
      • Delaney K.R.
      Looking 10 years back and 5 years ahead: Framing the clinical nurse specialists debate for our students.
      ). Additionally, there was clear evidence that the competencies (
      • American Nurses Association, American Psychiatric Nurses Association, & International Society of Psychiatric-Mental Health Nurses
      Psychiatric–mental health nursing: Scope and standards of practice.
      ,
      • Rice M.J.
      • Moller M.D.
      • DePascale C.
      • Skinner L.
      Achieving consensus on future credentialing for advanced practice psychiatric and mental health nursing.
      ) and educational programs were more similar than different. This was particularly true after the establishment of core competencies for the graduate education of all advanced practice nurses that included courses in pathophysiology, physical assessment, and pharmacology (the 3 Ps;
      • American Association of Colleges of Nursing
      The essentials of master's education for advanced practice nursing.
      , that up until that time were often lacking in PMH CNS programs.
      The primary PMH nursing associations, APNA and ISPN, solidified their position on PMH APRN roles in response to the Consensus Model for APRN Regulation, a document developed through the collaboration of nursing educational, accreditation, certification and licensing bodies across the United States (
      • National Council of State Boards of Nursing
      Consensus model for APRN regulation: Licensure, accreditation, certification & education.
      ). The Consensus Model provides guidance to states to adopt regulation of APRNs that is uniform across the country. APNA and ISPN convened a joint task force of PMH nursing leaders to develop recommendations for implementation of the Model for PMH APRNs (
      • Farley-Toombs C.
      Shaping the future of PMH-APRN practice through engagement.
      ,
      • Regan-Kubinski M.J.
      • Horton-Deutsch S.
      Update on advanced practice RN regulation and its application to advanced practice psychiatric mental health nursing.
      ). The task force forum also provided an opportunity to plan for the future of PMH advanced practice after careful consideration of the Consensus Model, trends in PMH APRN certification, transformation of the healthcare environment, changes in practice based on science, and the mental health needs of the population. The primary recommendation was that “there will be one entry educational focus for the future: PMH NP with preparation across the lifespan, addressing mental health promotion and mental illness diagnosis and treatment” (
      • American Psychiatric Nurses Association
      APNA Board of Directors Endorses APNA/ISPN Joint Task Force Recommendations on the Implementation of the “Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education”.
      ). Psychotherapeutic modalities were identified as essential content in educational programs (the fourth “P”). Additionally, PMH APRNs would continue to be able to practice under their current license and certification. The boards of both APNA and ISPN unanimously endorsed the recommendations.

      Practice patterns then and now

      In 1988, around the time of the study conducted by Dr. McBride and her colleagues, there were a total of 3497 PMH APRNs certified by ANCC as adult or child and adolescent CNSs (
      • Peterson B.D.
      • West J.
      • Pincus H.A.
      • Kohout J.
      • Pion G.M.
      • Wicherski M.M.
      • et al.
      An update on human resources in mental health.
      ). By 2012, there were over triple the number with over 13,000 certified PMH CNSs as well as NPs (N. Croce, personal communication, March 6, 2014) but the rate of growth in numbers of PMH APRNs is still discouragingly slow.
      There are only a few comprehensive surveys of PMH APRN practice, the most relevant for the purposes of this paper in 1995 (
      • Peterson B.D.
      • West J.
      • Pincus H.A.
      • Kohout J.
      • Pion G.M.
      • Wicherski M.M.
      • et al.
      An update on human resources in mental health.
      ) and 2007 (
      • Drew B.L.
      • Delaney K.R.
      National survey of psychiatric mental health advanced practice nursing: Development, process, and finding.
      ). While these sources do not allow a precise comparison of practice in 1987 and 2014, general trends in practice patterns of PMH APRNs over 27 years can be examined. There were 6030 certified PMH CNSs in 1995. The PMH NP certifications were relatively new and complete data were not available, so NPs were not included in the 1996 report. In 2007, however, 20% of the 10,001 certifications were for PMH NPs (
      • American Nurses Credentialing Center
      2007 ANCC certification data.
      ,
      • Drew B.L.
      • Delaney K.R.
      National survey of psychiatric mental health advanced practice nursing: Development, process, and finding.
      ). This trend in certifications is continuing with nearly 46% of the PMH APRN certifications for NPs (N. Croce, personal communication, March 6, 2014).
      Slightly more PMH APRNs were employed full time in 1995, 76% compared to 68.6% in 2007 with 85% providing direct care in 1994 compared to 93% in 2007. An estimated 49% worked in outpatient settings (clinics, individual, and group practice) in 1995; 65% in 2007. This suggests a transition from hospital-based care with approximately 29% of PMH APRNs employed in hospitals in 1995 and 20% during 2007.
      Perhaps the greatest shift in role definition was due to the addition of prescriptive authority to the scope of practice of PMH APRNs. Beginning in the 1980s with some states granting prescriptive privileges to some APRNs (
      • Talley S.
      • Brooke P.
      Prescriptive authority for psychiatric clinical specialists: Framing the issues.
      ), psychotropic medication evaluation, prescription and management have become a routine part of clinical practice for many PMH APRNs, now in all states.
      • Campbell C.D.
      • Musil C.M.
      • Zauszniewski J.A.
      Practice patterns of advanced practice psychiatric nurses.
      reported that 20% of PMH APRNs were prescribing in 1994. The proportion of prescribing PMH APRNs increased to 68% in 2007 (
      • Drew B.L.
      • Delaney K.R.
      National survey of psychiatric mental health advanced practice nursing: Development, process, and finding.
      ).
      The educational emphasis of the core APRN curriculum on pharmacology, physical assessment and pathophysiology along with the PMH specialty focus on psychotherapy modalities across the lifespan reinforced the value of the traditional consultation and liaison role (
      • McCorkle R.
      • Dowd M.
      • Ercolano E.
      • Schulman-Green D.
      • Williams A.
      • Siefert M.L.
      • et al.
      Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers.
      ) and resulted in a practitioner with a combination of skills that are desperately needed across systems of care. PMH APRNs are more likely now than in 1987 to be working in non-traditional settings—that is, settings whose primary function is not to provide mental health services but they are, nonetheless, called upon to do so. Examples of such workplaces include correctional settings (
      • Kent-Wilkinson A.E.
      Forensic psychiatric/mental health nursing: Responsive to social need.
      ), emergency departments (
      • Nicholls D.
      • Gaynor N.
      • Shafiei T.
      • Bosanac P.
      • Farrell G.
      Mental health nursing in emergency departments: The case for a nurse practitioner role.
      ), and schools (
      • DeSocio J.
      • Elder L.
      • Puckett S.
      Bridging cultures for Latino children: School nurse and advanced practice nurse partnerships.
      ).
      An additional health care setting that is ripe for advanced psychiatric nursing practice is the primary care clinic. Health care reform and the Affordable Care Act (ACA) have directed greater attention to health care practice that promotes holism, prevention of mental illness, and mental wellness promotion. With a large body of evidence that mental and physical health are inextricably linked (
      • Weiss S.J.
      • Haber J.
      • Horowitz J.A.
      • Stuart G.W.
      • Wolfe B.
      The inextricable nature of mental and physical health: Implications for integrative care.
      ) and direction from government policy-makers, many models for integration of primary care and behavioral health services have been developed (
      • Substance Abuse Mental Health Services Administration
      SAMHSA-HRSA Center for Integrated Health Solutions.
      ). Given their educational preparation, PMH APRNs are ideally suited to provide service in settings that integrate primary and behavioral health services (
      • Delaney K.R.
      • Robinson K.M.
      • Chafetz L.
      Development of integrated mental health care: Critical workforce competencies.
      ).

      Conclusion

      There is nothing like a walk back in time to be reminded of how the roles of psychiatric mental health nursing have evolved, sometimes with great turbulence, but always with great passion for our patients. I am grateful for the vision of Hildegard Peplau and her students who disseminated her traditions of patient-focused care, theory- and research-based interventions, and leadership in the profession of nursing. My gratitude extends to the scholarship of Dr. McBride and her colleagues whose work was among the earliest evaluations of the PMH advanced practice nursing.
      It is evident from this review that the advanced practice role of PMH nurses has adapted to meet the needs of society. As one of the five core mental health disciplines (
      • Health Resources and Services Administration
      Guidelines for mental health HPSA designation.
      ), there is a grave responsibility to continue to do so. What is also clear is the need to strengthen the PMH APRN workforce as health care reform is likely to increase demand for mental health services. This will require a rigorous graduate curriculum that is regularly updated to include emerging evidence-based practice (
      • Hoge M.A.
      • Stuart G.W.
      • Morris J.
      • Flaherty M.T.
      • Paris M.
      • Goplerud E.
      Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis.
      ); political activism to address regulatory barriers to the full scope of practice; and a systematic plan to increase and strengthen the PMH APRN workforce (
      • Hanrahan N.P.
      • Delaney K.R.
      • Stuart G.W.
      Blueprint for the development of the advanced practice psychiatric nurse workforce.
      ).

      References

        • American Association of Colleges of Nursing
        The essentials of master's education for advanced practice nursing.
        1996 (Washington, DC)
        • American Nurses Association, American Psychiatric Nurses Association, & International Society of Psychiatric-Mental Health Nurses
        Psychiatric–mental health nursing: Scope and standards of practice.
        American Nurses Association, Silver Spring, MD2014
        • American Nurses Credentialing Center
        2007 ANCC certification data.
        (Retrieved December 1, 2008, from)
        • American Psychiatric Nurses Association
        APNA Board of Directors Endorses APNA/ISPN Joint Task Force Recommendations on the Implementation of the “Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education”.
        (Retrieved from)
        • Bjorklund P.
        The certified psychiatric nurse practitioner: Advanced practice psychiatric nursing reclaimed.
        Archives of Psychiatric Nursing. 2003; 17: 77-87
        • Campbell C.D.
        • Musil C.M.
        • Zauszniewski J.A.
        Practice patterns of advanced practice psychiatric nurses.
        Journal of the American Psychiatric Nurses Association. 1998; 4: 111-120
        • Delaney K.R.
        The psychiatric nurse practitioner 1993–2003: A decade that unsettled a specialty.
        Archives of Psychiatric Nursing. 2005; 19: 107-115
        • Delaney K.R.
        Looking 10 years back and 5 years ahead: Framing the clinical nurse specialists debate for our students.
        Archives of Psychiatric Nursing. 2009; 23: 454-456
        • Delaney K.R.
        • Robinson K.M.
        • Chafetz L.
        Development of integrated mental health care: Critical workforce competencies.
        Nursing Outlook. 2013; 61: 384-391
        • DeSocio J.
        • Elder L.
        • Puckett S.
        Bridging cultures for Latino children: School nurse and advanced practice nurse partnerships.
        Journal of Child and Adolescent Psychiatric Nursing. 2008; 21: 146-153
        • Drew B.L.
        • Delaney K.R.
        National survey of psychiatric mental health advanced practice nursing: Development, process, and finding.
        Journal of the American Psychiatric Nurses Association. 2009; 15: 101-110
        • Farley-Toombs C.
        Shaping the future of PMH-APRN practice through engagement.
        Journal of the American Psychiatric Nurses Association. 2011; 17: 250-252
        • Hanrahan N.P.
        • Delaney K.R.
        • Stuart G.W.
        Blueprint for the development of the advanced practice psychiatric nurse workforce.
        Nursing Outlook. 2012; 60: 91-106
        • Health Resources and Services Administration
        Guidelines for mental health HPSA designation.
        (Retrieved from)
        • Hoge M.A.
        • Stuart G.W.
        • Morris J.
        • Flaherty M.T.
        • Paris M.
        • Goplerud E.
        Mental health and addiction workforce development: Federal leadership is needed to address the growing crisis.
        Health Affairs. 2013; 32: 2005-2012
        • Kent-Wilkinson A.E.
        Forensic psychiatric/mental health nursing: Responsive to social need.
        Issues in Mental Health Nursing. 2010; 31: 425-431
        • McBride A.B.
        • Austin J.K.
        • Chesnut E.E.
        • Main C.S.
        • Richards B.S.
        • Roy B.A.
        Evaluation of the impact of the clinical nurse specialist in a state psychiatric hospital.
        Archives of Psychiatric Nursing. 1987; 1: 55-61
        • McCorkle R.
        • Dowd M.
        • Ercolano E.
        • Schulman-Green D.
        • Williams A.
        • Siefert M.L.
        • et al.
        Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers.
        Psycho-Oncology. 2009; 18: 62-70
        • National Council of State Boards of Nursing
        Consensus model for APRN regulation: Licensure, accreditation, certification & education.
        (Retrieved from)
        • National Panel for Psychiatric-Mental Health NP Competencies
        Psychiatric–mental health nurse practitioner competencies.
        National Organization of Nurse Practitioner Faculties, Washington, DC2003
        • Nicholls D.
        • Gaynor N.
        • Shafiei T.
        • Bosanac P.
        • Farrell G.
        Mental health nursing in emergency departments: The case for a nurse practitioner role.
        Journal of Clinical Nursing. 2011; 20: 530-536
        • Peterson B.D.
        • West J.
        • Pincus H.A.
        • Kohout J.
        • Pion G.M.
        • Wicherski M.M.
        • et al.
        An update on human resources in mental health.
        in: Manderscheid R.W. Sonnenschein M.A. Mental health, United States. Substance Abuse and Mental Health Services Administration, Rockville, MD1996: 168-249 (DHHS Publication No. (SMA) 96–3098)
        • Regan-Kubinski M.J.
        • Horton-Deutsch S.
        Update on advanced practice RN regulation and its application to advanced practice psychiatric mental health nursing.
        Archives of Psychiatric Nursing. 2012; 26: 74-75
        • Rice M.J.
        • Moller M.D.
        • DePascale C.
        • Skinner L.
        Achieving consensus on future credentialing for advanced practice psychiatric and mental health nursing.
        Journal of the American Psychiatric Nurses Association. 2007; 13: 153-159https://doi.org/10.1177/1078390307305171
        • Rust J.E.
        Dr. Hildegard Peplau.
        Clinical Nurse Specialist. 2004; 18: 262-263
        • Spray S.L.
        The evolution of the clinical nurse specialist: An interview with Hildegard E. Peplau.
        Perspectives in Psychiatric Care. 1999; 35: 27-37
        • Substance Abuse Mental Health Services Administration
        SAMHSA-HRSA Center for Integrated Health Solutions.
        (Retrieved from)
        • Talley S.
        • Brooke P.
        Prescriptive authority for psychiatric clinical specialists: Framing the issues.
        Archives of Psychiatric Nursing. 1992; 6: 71-82
        • Weiss S.J.
        • Haber J.
        • Horowitz J.A.
        • Stuart G.W.
        • Wolfe B.
        The inextricable nature of mental and physical health: Implications for integrative care.
        Journal of the American Psychiatric Nurses Association. 2009; 15: 371-382