Role Development of Psychiatric Mental Health Nurse Practitioners

Role Development of Psychiatric Mental Health Nurse Practitioners (PMHNPs)

Introduction

Roles for nurses continue to evolve as nurses find a way to satisfy the growing and expanding needs of a wide range of patients and communities throughout our population. Psychiatric mental health nurse practitioners (PMHNPs) are taking increasing clinical responsibilities when providing mental health care to individuals with a wide variety of mental diseases (de Nesnera & Allen, 2016).

Review of Literature

Literature Searching Strategy

Seven databases were searched, including CINAHL, MEDLINE, PsycINFO; PubMed, ProQuest Central, Google Scholar, and Cochrane Library (2/2014-2/2019). Search terms were: PMHNPs, psychiatric nurse practitioners, role development, mental health, mental health advanced practice registered nurses and psychiatric nursing.

Defining Characteristics

PMHNPs are the advanced practice registered nurses (APRNs) (DeNisco & Barker, 2016). PMHNPs hold a master degree and deliver a wide variety of mental health services including diagnosis and management of both acute and chronic mental illness, prescribing, and providing psychotherapy (Delaney, Drew, & Rushton, 2018). Services of PMHNPs improve access and quality of public mental health care.

Historical Development

The first master-level psychiatric nursing program in the United States was started at Rutgers University in 1955 (Rutgers University, 2014). Advanced practice psychiatric mental health nursing began with psychiatric mental health clinical nurse specialists (PMHCNS), was the first advanced practice nurses (APNs) at that time (Hein, & Scharer, 2015). Nurse practitioner (NP) roles sprung up in diverse specialties in the 1970s. Nevertheless, the role grew slowly in psychiatric nursing because PMHCNSs were already contributing almost all of the functions of NPs, besides prescribing medications (de Nesnera & Allen, 2016). Numerous organizations of psychiatric mental health nurses were generated in the 1980s. The topic of whether keeping the PMHCNS or PMHNP, or both had become a major controversy (Giardino, Giardino, & Hanks, 2014). In 2008, the American Association of Colleges of Nursing (AACN) released a report explaining standards for APRN education, practice, and regulation-the LACE document (Hein, & Scharer, 2015). After the LACE document was accepted, American Nurses Credentialing Center (ANCC) removed the PMHCNS exam at the end of 2014, but PMHCNS is able to continue re-certification (Giardino et al., 2014). With a lack of psychiatrists and a growing demand for mental health service, PMHNPs have the potential to bridge this widening gap (Theccanat, 2015). The need is being filled by PMHNPs in the US workforce increasing 69% by 2025 (Levin, 2017).

Regulations

The model of LACE organizes how licensure, accreditation, certification, and education are to align (Vanderhoef & Delaney, 2017). PMHNPs typically have earned a graduate degree such as a master’s degree in nursing or a doctorate completed as part of their basic registered nurse training (Balestra, 2018). AACN advised progress APRN education to the doctor of nursing practice (DNP) level (Weber, Delaney, & Snow, 2016). PMHNPs must pass a national certification examination offered by ANCC or American Association of Nurse Practitioners (AANP) (Fitzpatrick, Ea, & Bai, 2017). Certification is good for five years. Continuing education from approved organizations is required to renew certification. PMHNPs hold two board-issued credentials: RN licensing and PMHNP certification. Basic life support and advanced cardiac life support certifications are also required (Fitzpatrick, et al., 2017). States vary widely in their laws and administrative rules outlining PMHNP’s scope of practice (de Nesnera & Allen, 2016). All states currently allow PMHNPs to prescribe medications and provide clinical care to patients. Remarkably, federal law requires that NPs obtain a Drug Enforcement Administration number in order to write prescriptions for medications classified as controlled substances (Kane, 2015). The responsibilities of PMHNPs include assessment and diagnosis of psychiatric disorders, appropriate treatment of mental disorders, and familiarity with all current medical terminology and with reimbursement and coding (Theccanat, 2015).

Professional Organizations

There are four associated professional organizations: AANP, ANCC, American Psychiatric Nurses Association (APNA), and International Society of Psychiatric–Mental Health Nurses (ISPN) (Fitzpatrick, et al., 2017).

AANP stands at the central hub of this growing health care profession and research. AANP is the home of the nation’s most robust database of information about NPs, as well as their practices (AANP, 2017). ANCC develops customized credentials that validate the expertise of PMHNPs. The certification of PMHNP-BC supports the mission and vision of the workplaces and reinforces the specific skills and knowledge. APNA was founded in 1986 and has grown to be the largest professional membership organization to fill the professional needs of mental health nursing, which focuses on wellness promotion, prevention of mental health problems, and the treatment of persons with psychiatric disorders (Beeber, 2017). APNA is a resource for networking, learning, and dissemination of research. ISPN was established in 1999 and conducts fantastic leadership for advanced practice psychiatric nurses (ISPN, 2014). ISPN supports PMHNPs in improving mental health care, knowledge, and policy worldwide (Soltis-Jarrett, Shea, Ragaisis, Shell, & Newton, 2017).

Current Practice Settings

They function to diagnose and treat patients with psychiatric illnesses and oversee care in the inpatient and outpatient settings (Fitzpatrick et al., 2017). The APNA recognizes and promotes the integration of PMHNPs with advanced skills in psychiatry into a wide variety of psychiatric practice settings, such as emergency rooms, hospital, outpatient settings, home-based care settings, nursing homes, school, shelters, research organizations, veterans’ facilities and psychiatric inpatient units (de Nesnera & Allen, 2016; Theccanat, 2015).

Relationship to Other Health Care Team Members

Leadership, effective teamwork, and the empowerment of teams have been critical factors in the evolution of continuous quality improvement in health care (DeNisco & Barker, 2016). As psychiatric physician shortages and maldistribution persist in the United States, the role of the PMHNP will continue to expand, and PMHNPs’ training and their ability to collaborate with physicians are becoming increasingly appreciated (Lake, & Turner, 2017). A truly collaborative team of primary care and behavioral health clinicians is needed. Team-based care should also include other professionals, such as psychiatric social workers, psychologists, and psychiatrists, registered nurses, unit secretaries, behavioral health assistants, mental health and occupational therapists (Shattell, 2017). Nursing and non-nursing staffs work together and use a cost-effective approach to provide patient-centered care for the defined population.

Interview

I talked to a PMHNP, and discussed about the role, responsibilities, barriers and resources of PMHNPs. He provided a great example of PMHNP practice:

After I graduated in August 2016, I started in a small office in Long Island with only social workers and one PMHNP. They needed another new graduate PMHNP for patients who required medication management. I was there for two years. I also have been doing a per diem job in a clinic in Brooklyn since 2017, performing same duties, conducting psychiatric evaluations and medication management. Currently, I work as an associate director of the Mobile Crisis Unit Woodhull Hospital in Brooklyn since September 2018. With the associate director position, I do administrative work related to the role, operationally. The Mobile Crisis Unit receives referrals from various sources, such as therapists, social workers, private psychiatrist, family, friends and Comprehensive Psychiatric Emergency Program (CPEP) who have psychiatric concern about the people. Mobile Crisis then goes out and sees patients at their homes to assess them if they are available or interested, and determines if there is a need for continued outpatient treatment. My department assists in connecting the patients to a mental health treatment facility. However, on the other hand, my department provides voluntary service, so the patients we see may refuse our services, as long as they are alert, oriented, and in no mental health distress or a danger to themselves or others. If any patient fits any of the criteria mentioned, then I have the authority to remove them involuntarily and send them to a hospital. So far I have not had the opportunity to do it, but it came close to do that twice. I also work in the CPEP (Psych ER) one day per week which still a part of the Mobile Crisis job, doing assessments to determine if patients can be admitted or discharged. It can be challenging if you are not confident or comfortable in your role. Also, this is a role that experience is your best teacher. There was so much that the school curriculum did not cover. Many psychiatric books out there to provide newest knowledge. I read what I can when I have the time. I did my reading as I go along and especially if I’m not sure about certain diagnosis and medications. I also have a collaborating MD to assist me when I am in need. (Lindsay, 2019, February 10)

Personal Development

Theoretical Model

The Sanctuary Model is a trauma-informed organizational change intervention developed by Sandra Bloom and colleagues in the early 1980s (Esaki et al., 2014). The Sanctuary Model, an evidence-supported, relationship-based, high-commitment, high-performance organizational development approach, enables a program, a system, or a community to consciously and deliberately design or redesign their workplaces so that establishing and maintaining safe moral climates becomes possible (Bloom, 2017). The Sanctuary Model’s focuses not only on the people who seek treatment but equally on the people and systems who provide that treatment (Cotraccia, 2015). Operating on two distinct levels, namely organizational culture, and therapeutic care, the Sanctuary Model provides the foundation for healing and growth (Leigh-Smith, & Toth, 2014).

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The Sanctuary Model is currently being used as a systematic organizational change process for over 250 human service delivery systems around the country and internationally (Cotraccia, 2015). The community can be enhanced by faithfulness to the seven Sanctuary commitments of non-violence, emotional intelligence, democracy, open communication, social responsibility, social learning, and growth and change (Esaki et al., 2013). These seven commitments are the shared values that guide an organization to create Sanctuary. The sanctuary model has outlined outcomes, such as reducing restraint use and increasing staff retention and morale (Matey, 2014). The implementation of the Sanctuary Model was also significantly associated with improved organizational culture and climate (Kramer, 2016). This trauma-informed model can benefit the role development of PMHNPs and strengthen the therapeutic environment for staff and patients. The Sanctuary Model creates a healing environment for trauma victims through improved structures, processes, and behaviors for all community members (Newman, Paun, & Fogg, 2018).

Personal Characteristics

I was born in a medical family, I have full of enthusiasm about patient care from my childhood. The education from my parents cultivated the core values that shaped me into a person who has compassion, and genuineness. I am motivated to be the best that I can be. With first-hand experience in the psychiatric area, both with taking care of my depressed father and working on an inpatient behavioral health unit, I want to become a PMHNP. Under the call of the Einstein health network, I achieved my psychiatric-mental health nursing certification (RN-BC) last year and working on my master degree now. I become more confident, knowledgeable and assured of my role in providing patient-centered excellent mental health services. Because I firmly believe my lifelong pursuit is advancing both my talents and endowments to make a difference in mental health patients’ lives.

Learning Needs

To qualify for the role of PMHNP, I need to discover more about finance, laws, and policies which will be helpful to understand mental health current conditions and development. In order to enhance professional development, I will keep abreast of current research and literature regarding clinical practice and trends. It is also vital to learn leadership skills to meet the challenges of this profession and role transition.

Development Goals

After the MSN program, I hope I can apply the strategies of interview and assessment skills into clinical practice. I will be able to provide compassionate, appropriate, and effective treatment to patients. I will enable to effectively exchange of information and collaboration with patients, their families, and other health specialists with interpersonal and communication skills. I also wish I will have opportunities to develop research skills and conduct researches in psychiatric fields.

References

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• Bloom, S. L. (2017). The sanctuary model: Through the lens of moral safety. APA handbook of trauma psychology: Trauma practice, 2, 499–513. doi:10.1037/0000020-024
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