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 et al., 1987
). 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, 2004
). Under Peplau's direction, the emphasis of the CNS graduate program grew to focus on the development of skills in psychotherapy (Spray, 1999
). 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 et al., 1987
. 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, 2003
). 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, 2005
). 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, 2003
helped to standardize curricula, to some degree (Delaney, 2005
).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, 2005
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, 2009
). Additionally, there was clear evidence that the competencies (American Nurses Association, American Psychiatric Nurses Association, and International Society of Psychiatric-Mental Health Nurses, 2014
, Rice et al., 2007
) 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; - 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
American Association of Colleges of Nursing, 1996
, 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, 2008
). 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, 2011
, Regan-Kubinski and Horton-Deutsch, 2012
). 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, 2011
). 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 et al., 1996
). 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 et al., 1996
) and 2007 (Drew and Delaney, 2009
). 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, 2008
, - American Nurses Credentialing Center
2007 ANCC certification data.
www.nursecredentialing.org
Date: 2008
Drew and Delaney, 2009
). 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 and Brooke, 1992
), psychotropic medication evaluation, prescription and management have become a routine part of clinical practice for many PMH APRNs, now in all states. Campbell et al., 1998
reported that 20% of PMH APRNs were prescribing in 1994. The proportion of prescribing PMH APRNs increased to 68% in 2007 (Drew and Delaney, 2009
).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 et al., 2009
) 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, 2010
), emergency departments (Nicholls et al., 2011
), and schools (DeSocio et al., 2008
).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 et al., 2009
) 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, n.d
). Given their educational preparation, PMH APRNs are ideally suited to provide service in settings that integrate primary and behavioral health services (Delaney et al., 2013
).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, n.d
), 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 et al., 2013
); 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 et al., 2012
).References
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Published online: July 22, 2014
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© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
