- Read the given text and answer the following questions:
1. How does the sScope and Standards of Practice for PMHAPNs address the practice of psychotherapy from both a historical and contemporary standpoint?
2. Identify 3 changes in health care and/or psychiatric advanced practice nursing that have impacted the practice of psychotherapy in the past few decades?
3. APNA (American Psychiatric Nurses Association) is having their annual conference this fall in Florida. Examine the offerings at this conference. What are your thoughts and opinions about the offerings on psychotherapy?
History and Evolution of Psychiatric-Mental Health Nursing
Psychiatric-mental health nursing began with late 19th century reform move- ments to change the focus of mental asylums from restrictive and custodial care to medical and social treatment for the mentally ill. The “first formally organized training school within a hospital for insane in the world” was estab- lished by Dr. Edward Cowles at McLean Asylum in Massachusetts in 1882 (Church, 1985). The use of trained nurses, rather than “keepers,” was central to Cowles’ effort to replace the public perception of “insanity” as deviance or infirmity with a belief that mental disorders could be ameliorated or cured with proper treatment. The McLean nurse training school was the first in the United States to allow men the opportunity to become trained nurses (Boyd, 1998). Eventually, asylum nursing programs established affiliations with general hospitals so that general nursing training could be provided to their students.
Early on, training for psychiatric nurses was provided by physicians. The first nurse-organized training course for psychiatric nursing within a general nursing education program was established by Effie Jane Taylor at Johns Hopkins Hospital in 1913 (Boyd, 1998). This course served as a prototype for other nursing education programs. Taylor’s colleague Harriet Bailey published the first psychiatric nursing textbook, Nursing Mental Disease, in 1920 (Boling, 2003). Under nursing leadership, psychiatric-mental health nursing developed a biopsychosocial approach with specific nursing methods for individuals with mental disorders. The PMH nurse also began to identify the didactic and clini- cal components of training needed to care for persons with mental disorders. In the post-WWI era, “nursing in nervous and mental diseases” was added to curriculum guides developed by the National League for Nursing Education and was eventually required in all educational programs for registered nurses (Church, 1985).
The next wave of mental health reform and expansion in psychiatric nursing began during World War II. The public health significance of mental disorders became widely apparent when a significant proportion of potential military recruits were deemed unfit for service as a result of psychiatric disability. In addition, public attention and sympathy for the large number of veterans with combat-related neuropsychiatric casualties led to increased support for improv- ing mental health services. As a psychiatric nurse consultant to the American Psychiatric Association, Laura Fitzsimmons evaluated educational programs for psychiatric nurses and recommended standards of training. These recom- mendations were supported by professional organizations and backed with federal funding to strengthen educational preparation and standards of care for psychiatric nursing (Silverstein, 2008).
The national focus on mental health, combined with admiration for the heroism shown by nurses during the war, led to the inclusion of psychiatric nursing as one of the core mental health disciplines named in the National Mental Health Act (NMHA) of 1946. This act greatly increased funding for psychiatric nursing education and training (Silverstein, 2008) and led to a growth in university-level nursing education. In 1954, Hildegard Peplau estab- lished the first graduate psychiatric nursing program at Rutgers University.
The post-war era was marked by growing professionalization in psychi- atric-mental health nursing (PMH). Funding provided by the NMHA led to a rapid expansion of graduate programs and the start of psychiatric-mental health nursing research. In 1963, the first journals focused on psychiatric- mental health nursing were published. In 1973, the ANA first published the Standards of Psychiatric-Mental Health Nursing Practice and began certify- ing generalists in psychiatric-mental health nursing (Boling, 2003). Peplau’s Interpersonal Relations in Nursing (1992), which emphasized the importance of the therapeutic relationship in helping individuals to make positive behav- ior changes, articulated the predominant psychiatric-mental health nursing approach of the period.
The process of deinstitutionalization began in the late 1950s when the majority of care for persons with psychiatric illness began to shift away from hospitals and toward community settings. Contributing factors included the establishment of Medicare and Medicaid, changing rules governing involuntary confinement, and the passage of legislation supporting construction of com- munity mental health centers (Boling, 2003). Although psychiatric-mental health nurses prepared at the undergraduate level continued to work primar- ily in hospital-based and psychiatric acute care settings, many also began to practice in community-based programs such as day treatment and assertive community treatment.
Mental health care in the United States began another transformation in the 1990s, the “Decade of the Brain.” The dramatic increase in the number of psychiatric medications on the market, combined with economic pressures to reduce hospital stays, resulted in briefer psychiatric hospitalizations char- acterized by use of medication to stabilize acute symptoms. Shorter hospital stays and higher patient acuity began to shift psychiatric nursing practice away from the emphasis on relationship-based care advocated by Peplau and toward interventions focused on stabilization and immediate safety. Psychiatric-mental health nursing education began to include more content on psychopharmacol- ogy and the pathophysiology of psychiatric disorders.
More recent trends in psychiatric-mental health nursing include an empha- sis on integrated care and treatment of those persons with co-occurring psy- chiatric and substance use disorders, as well as integrated care and treatment of those with co-occurring medical and psychiatric disorders. Integrated care emphasizes that both types of disorders are primary and must be treated as such.
Since the Substance Abuse and Mental Health Services Administration (SAMHSA) has declared that recovery is the single most important goal in the transformation of mental health care in America (SAMHSA, 2006), psychiatric-mental health nursing is moving to integrate person-centered, recovery-oriented practice across the continuum of care. This continuum includes settings where psychiatric-mental health nurses have historically worked, such as hospitals, as well as emergency rooms, jails and prisons, and homeless outreach services. Psychiatric-mental health nursing is also tasked with developing and applying innovative approaches in caring for the large population of military personnel, veterans, and their families experiencing war-related mental health conditions as a result of military conflicts.
Major developments in the nursing profession have a corresponding effect within psychiatric-mental health nursing. The Institute of Medicine’s (2010) report, The Future of Nursing: Leading Change to Advance Health has strengthened the role of psychiatric-mental health nurses as mental health policy and program development leaders in both national and international arenas. Nursing’s emphasis on the use of research findings to develop and implement evidence-based practice is driving improvements in psychiatric- mental health nursing practice.
Origins of the Psychiatric-Mental Health Advanced Practice Nursing Role
Specialty nursing at the graduate level began to evolve in the late 1950s in response to the passage of the National Mental Health Act of 1946 and the creation of the National Institute of Mental Health in 1949. The National Mental Health Act of 1946 identified psychiatric nursing as one of four core disciplines for the provision of psychiatric care and treatment, along with psychiatry, psychology, and social work. Nurses played an active role in meet- ing the growing demand for psychiatric services that resulted from increasing awareness of post-war mental health issues (Bigbee & Amidi-Nouri, 2000). The prevalence of “battle fatigue” led to recognizing the need for more mental health professionals.
The first degree in psychiatric-mental health nursing, a master’s degree, was conferred at Rutgers University in 1954 under the leadership of Hildegard Peplau. In contrast to existing graduate nursing programs that focused on developing educators and consultants, graduate education in psychiatric-mental health nursing was designed to prepare nurse therapists to assess and diag- nose mental health problems and psychiatric disorders and provide individual, group, and family therapy. Psychiatric nurses pioneered the development of the advanced practice nursing role and led efforts to establish national certi- fication through the American Nurses Association.
The Community Mental Health Centers Act of 1963 facilitated the expan- sion of psychiatric-mental health clinical nurse specialist (PMHCNS) practice into community and ambulatory care sites. PMHCNSs with master’s and doc- toral degrees fulfilled a crucial role in helping deinstitutionalized mentally ill persons adapt to community life. Traineeships to fund graduate education pro- vided through the National Institute of Mental Health played a significant role in expanding the PMHCNS workforce. By the late 1960s, PMHCNSs provided individual, group, and family psychotherapy in a broad range of settings and obtained third-party reimbursement. PMHCNSs also functioned as educators, researchers, and managers, and worked in consultation-liaison positions or in the area of addictions. These roles continue today.
Another significant shift occurred as research renewed the emphasis on the neurobiologic basis of mental disorders, including substance use disor- ders. As more efficacious psychotropic medications with fewer side effects were developed, psychopharmacology assumed a more central role in psychi- atric treatment. The role of the PMHCNS evolved to encompass the expand- ing biopsychosocial perspective, and the competencies required for practice
were kept congruent with emerging science. Many psychiatric-mental health graduate nursing programs added neurobiology, advanced health assessment, pharmacology, pathophysiology, and the diagnosis and medical management of psychiatric illness to their curricula. Similarly, preparation for prescriptive privileges became an integral part of advanced practice psychiatric-mental health nursing graduate programs (Kaas & Markley, 1998).
Other trends in mental health and the larger healthcare system also sparked significant changes in advanced practice psychiatric nursing. These trends included:
■ AshiftinNationalInstituteofMentalHealth(NIMH)fundsfrom education to research, leading to a dramatic decline in enrollment in psychiatric nursing graduate programs (Taylor, 1999);
■ Anincreasedawarenessofphysicalhealthproblemsinmentallyill persons living in community settings (Chafetz et al., 2005);
■ Ashifttoprimarycareasakeypointofentryforcomprehensive health care, including psychiatric care; and
■ Thegrowthandpublicrecognitionofthenursepractitionerrolein primary care settings.
In response to these challenges, psychiatric nursing graduate programs modified their curricula to include greater emphasis on comprehensive health assessment, referral, and management of common physical health problems, and a continued focus on educational preparation to meet the state criteria and professional competencies for prescriptive authority. The tremendous expansion in the use of “nurse practitioners” in primary care settings had made nurse practitioner (NP) synonymous with “advanced practice registered nurse” in some state nurse practice acts and for many in the general public. In response to conditions including public recognition of the role, market forces, and state regulations, psychiatric-mental health nursing began utilizing the Nurse Practitioner title and modifying graduate psychiatric nursing programs to conform to requirements for NP credentialing (Wheeler & Haber, 2004; Delaney et al., 1999). The Psychiatric-Mental Health Nurse Practitioner role was clearly delineated by the publication of the Psychiatric-Mental Health Nurse Practitioner Competencies (National Panel, 2003), the product of a panel with representation from a broad base of nursing organizations sponsored by the National Organization of Nurse Practitioner Faculty (NONPF).
Whether practicing under the title of clinical nurse specialist (CNS) or NP, Psychiatric-Mental Health Advanced Practice Registered Nurses share the same core competencies of clinical and professional practice. Although psychiatric- mental health nursing is moving toward a single national certification for new graduates of advanced practice programs, titled Psychiatric-Mental Health Nurse Practitioner, persons already credentialed as Psychiatric-Mental Health Clinical Nurse Specialists will continue to practice under this title (NCSBN Joint Dialogue Group Report, 2008).
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