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Psychiatric Mental Health Advanced Practice Regist ...
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Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I am pleased that you are joining us today for today's SMI Advisor webinar, Psychiatric Mental Health Advanced Practice, Registered Nurses, Evolving Roles. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an AAPA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary efforts have been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. Donna Rowland. Dr. Rowland is a Clinical Associate Professor and the Director of the Psychiatric Mental Health Nurse Practitioner Program at the University of Texas. She serves on the National Board of Directors of the American Psychiatric Nurses Association and is a core member of SMI Advisor's Clinical Expert Team. Donna, thank you so much for being here and joining us at AAPA for today's webinar. Thank you, Dr. Grindow, for that introduction. One of my goals today is to decode my credentials for anyone not privy to the secret alphabet of advanced practice nursing. I have no relationships or conflicts of interest to disclose. Not only is this content ambiguous to other disciplines, it is unclear and misunderstood within the nursing discipline as well. Objectives of this presentation include sorting out the confusing evolution of the psychiatric mental health advanced practice registered nurse's role development, distinguishing among the roles and clarifying, and discussing workforce trends. We will review history and tradition of the PMH-APRN roles, the LACE consensus model, scope and standards that define PMH-APRN practice, and current psychiatric workforce, or where you will find PMH-APRNs and what they can do. APRNs include four overall designations, nurse practitioners who originally worked in primary care settings and have various specialty types, clinical nurse specialists originally working in systems and organizations, facility-based, also having various specialty types, certified nurse midwives working in labor and delivery, and CRNAs working in the operating room. Here we'll focus on nurse practitioners and clinical nurse specialists where psychiatric mental health nursing has specialized. This whole story began in the 1950s at Rutgers University where the psych mental health clinical nurse specialist program opened with a grant by NIMH. By 1965, there were 30 such PMH-CNS programs. These programs were focused on psychotherapy, organizational dynamics, and the consultation liaison role and practices. This was an independent role. In the 1990s, psychiatric mental health nurse practitioner programs began opening following other NP specialty programs. Psychiatric mental health nurse practitioners have the initials PMH-NP because the PMP initials were taken by the pediatric nurse practitioners who happened to be the first NP specialty. In the 1990s, managed care changes, effective reimbursement models, and primary care roles were becoming the majority. Some of the earliest psych NP programs were at Fairfield University and New York University, which were started by HRSA grants by Dr. Kate Wheeler and Dr. Madeline Nagel. In 1997, Vanderbilt University opened a psychiatric NP program. These are some of the earliest programs, followed in 2002 by Rush University and various other schools. The University of Texas program opened in 2008. In 1999, ANCC, or the American Nursing Credentialing Center, developed two exams, the adult PMH-NP and the family PMH-NP exams. These were offered for the first time in 2000. In the late 1990s, this was the height of the debate and confusion continuing regarding the roles of the PMH-CNF versus the PMH-NP as their overlap and competition was very confusing. The LACE model, which we'll learn more about shortly, was an early development attempting to achieve consensus among various roles of APRNs. PMH-NP graduate curricula shifted emphasis to primary care models of assessment, psychoeducation, brief therapy, and interventions focusing on diagnosis and pharmacotherapy. Shared core APRN competencies were established by the American Association of Colleges of Nursing in 1996. And incidentally, in 1999, the International Society of Psychiatric Mental Health Nurses was formed. In the 2000s, the AACN released the LACE consensus model for APRN regulation. LACE stands for Licensure Accreditation Certification and Education. This document was to be fully implemented by 2015. We'll talk more about this in just a moment. In 2007, Dr. Rice completed a logical job analysis comparing PMH-CNF versus PMH-NP roles and found only a 1% variation in tasks. In 2010, the PMH-NP lifespan became the sole entry-level APRN designation to practice in 2010, no longer the PMH-CNF role. The AACN at this time proposed the Doctor of Nursing Practice to become the advanced practice standard by 2015, which has not yet taken hold. The National Organization of Nurse Practitioner Faculty committed to move this entry-level NP education to the Doctor of Nursing Practice by 2025 in the statement issued last year. Yet currently, both MSN and DNP programs remain as well as post-master's DNP programs. LACE is the name of the consensus model for all APRNs released in 2008. Again, it stands for Licensure Accreditation Certification and Education. I will walk through each element of this model. I will do this in order in which they logically flow, which is the AELC, which does not make for a nice acronym. A, accreditation. In the case of APRNs, this is granted to colleges and universities whereby they are accredited and recognized for verification that predetermined standard criteria have been met in their curricula. Two, education. According to the LACE consensus model, colleges and universities are to agree to follow the agreed-upon LACE standards. For education, these include curricula that follow APRN standards and competencies, holding accreditation, producing transcripts detailing the role and lifespan population focus, and assuring that graduates meet eligibility requirements to sit for certification exams. Third, licensure. State board agencies grant permission to APRNs to engage in practice and utilize the title with the purpose of protecting the public. For example, this yields a state license as an APRN, specifically as a PMH MP, without the BC after it. Four, certification. National certification agencies, here in the case of PMH CNS and PMH MP, is ANCC, the American Nurses Credentialing Center. This agency grants recognition to APRNs whereby they are given credentials that validate the predetermined knowledge and practice standards that have been met by examination. This yields a national certification as a PMH MP-BC. This grants the board certification. So, back to decoding my credentials. First, I have the PhD. This is the highest degree earned, and for APRNs, it can be a PhD, a DNP, an MSN, or a DNSC. Next, you have the APRN license. Most states are using APRN. Occasionally, you'll see ARNP in a few states that remain. Lastly, you'll see the PMH CNS or the PMH MP, which is the licensure and certification followed by BC for board certification. Prior to the Lease Consensus Model implementation, there were numerous PMH APRN roles yielding certification and credentials. PMH CNS training required choosing between the adult, adult PMH CNS, or child adolescent, PMH CNS populations, and did not offer a lifespan certification. PMH MP role options previously included either adult PMH MP or lifespan slash family FPMH MP populations. Since January 1st, 2017, the only credential awarded is the lifespan PMH MP. PMH MP is the credential granted, which is the same as the previous FPMH MP, but has dropped the F from the beginning of the credential, since all of the currently educated PMH MPs are lifespan family trained. And also, the F was confusing. Many thought that it was a combo dual certification of psych MP and family nurse practitioner, which it was not. The original intent of the PMH CNS role was primarily that of an independent psychotherapy and consultation role, including much content on such. PMH MP programs inherited these competencies following the implementation of the Lease Consensus Model and consolidation of the PMH APRN roles, yet many PMH MPs trained during the time prior to this implementation and were not trained in psychotherapy or consultation competencies. This was a contentious point of debate during the time at which Lease decisions were being made, and important to note about the scope of PMH MPs educated during this gap between 2008 and 2015. Quotes are included from Dr. Judy Haber and Dr. Kate Wheeler, leaders in psychiatric mental health nursing and pioneers in PMH MP programs at New York University and Fairfield University. Additionally, the debate about the necessary therapy skillset for PMH APRNs persists, as it does in much psychiatric and psychological education. The last application for the PMH CNS certification exam was accepted at the end of 2016. PMH CNS programs have closed or transitioned into PMH MP programs. As mentioned previously, the psychotherapy and consultation systems roles have shifted to now be within the scope of PMH MPs. Any previously certified PMH CNSs or PMH MPs under prior designations, such as child-adolescent PMH CNS or adult PMH MP, are able to remain certified and able to practice as long as they maintain licensure and certification requirements and do not allow such to lapse. There's no active examination that would allow them to recertify by examination, therefore additional education would be required if their certification were to lapse. Open standards are the specialty's guide to competent nursing practice. Scope identifies the focus of the specialty by defining what is within limits of nursing practice. Standards are the responsibilities for which RNs and APRNs are held accountable. Scope and standards of psychiatric mental health nursing are established jointly by the American Psychiatric Nursing Association, the International Society for Psychiatric Nursing, and the American Nursing Association, and they are updated every five years, currently undergoing revision right now. The National Organization of Nurse Practitioner Faculties provides support to educators through establishing competencies, methods of evaluation, and by working with collaborators to achieve excellence in NP education. NP core and specialty competencies are outlined in great detail, and these go through regular updates as well. Through national targeted exams that incorporate the latest clinical practices and require renewal every five years, ANCC certification provides evidence to the public that the certified individual is meeting requirements for continued competence by updating his or her knowledge and showing commitment to lifelong learning. These three prior standards do provide curriculum determination, yet there is still much variation between program structure, educational administration, and clinical processes. Many facets of APRN education may still be left up to the school and faculty to determine, including much flexibility on issues of clinical practica, psychotherapy content, and course delivery. In 2008, when LACE was being launched, Drs. Kate Wheeler and Kathy Delaney, two leaders in psychiatric mental health nursing, completed a national survey of 68 PMH APRN programs. They found that 84% offered PMH and P programs, 62% offered PMH CNS programs, and at that time, 38% offered combination programming. A plurality of psychotherapy approaches and models were being taught, and 80 different textbooks were being utilized across programs, for example. As far as practicum hours and psychotherapy were concerned, Drs. Wheeler and Delaney found much variation in how programs were having students fulfill psychotherapy clinical hours. 50% of programs had specified practice hours by psychotherapy modalities, and 50% of programs combined psychiatric management, or diagnosis and management hours, with the psychotherapy hours. Ranges of required psychotherapy practicum hours ranged greatly by program as specified, but most programs did not specify such. Notably, also, some programs surveyed were MSN programs and others were DNP. This explains the great range in total program clinical hours. In 2014, I conducted a small follow-up study of PMH APRN programs selected from top programs nationwide. Again, programs included both MSN and DNP levels, yielding a great range of total program clinical hours. AMCC requires 500 clinical hours minimum in order to certify PMH MPs currently. Therefore, most MSN programs range from 550 to 650 total hours required. Most DNP programs require 1,000 clinical practicum project total hours. Psychotherapy practicum hours are achieved by programs in various ways, utilizing treatment of addiction exposure, lab hours with two-way mirror patient recordings, group therapy sessions, and simulations for such, in preparation for live group therapy sessions. Supportive therapy augmentation to medication management sessions are also utilized. What psychotherapy content is being taught to PMH APRNs and how? A range of psychotherapy content is taught to PMH APRNs, depending on school preferences, ranging from traditions to contemporary choices, inclusion of focus on substance use disorders or not, availability of preceptors from various disciplines, NP psychiatrists, but often various therapists, such as psychologists, LCSWs, LMFTs, LPCs, et cetera. The scope and standards, the NOMS NP competencies in AMCC dictate only a few specifics, mainly from NOMS. These are supportive, psychodynamic, and CBT, and that the PMH NPs learn other evidence-based therapies. Neither scope and standards nor NOMS competencies or AMCC certification requirements specify how to provide psychotherapy clinical experiences. Now we will look at the specific sources that determine PMH APRNs practice. Essentially, scope defines psychomental health nursing, describes evolutions, levels of practice related to educational preparation, types of practice, activities, and sites, current trends and issues relevant to psychiatric mental health nursing, or descriptive breadth of practice. Functions and roles of PMH APRNs are included in the scope of PMH APRNs. Standards are authoritarian statements describing responsibilities for which PMH nurses are accountable for standards of care. Still, state nurse practice acts and statutes set and enforced laws and penalties. Scope and standards are the basis for the practice definition. State nurse practice acts may limit the scope and standards, as we will address later. You can see on this slide the overall functions and roles of PMH APRNs. As the outline scope above, including psychotherapy, psychopharmacological intervention, case management, program development and management, health teaching and health screening, consultation liaison, clinical supervision, and since 2014, management of common medical illnesses and behavioral and integrated healthcare. The National Organization of Nurse Practitioner Faculties competencies includes both core NP competencies shared by all NP specialties. These are based on both AACNs, masters and DNP essentials, including content such as research, health policy, quality and safety, and health leadership. PMH NP specialty competency content includes materials specific to PMH NPs, such as psychiatric diagnosis and management, psychopharmacology, psychotherapy, and consultation liaison roles. Based on NAMS competencies specific to PMH NPs, psychotherapy education incorporates evidence-based models of therapy, such as supportive psychotherapy, which focuses on building an alliance with the patient that encourages emotional processing and strength building, psychodynamic principles, which aim to facilitate healthy attachment behaviors, interpersonal and interpersonal functioning, and cognitive behavioral therapy, which focuses on the improving unhealthy processes linked by thoughts, feelings, and behaviors. In addition to individual therapy, education also focuses on family and group approaches to care, trauma-informed treatment, and a recovery-oriented perspective, imperative to practicing therapy or learning to develop beneficial therapeutic relationships with clients and the use of self-reflective practice to improve care. In addition to scope and standards and the NAMS competencies, which are embedded in PMH NP educational programming, PMH NP students must also meet criteria for eligibility to sit for the ANCC certification exam. These include core NP courses, specialty NP courses, and a minimum of 500 faculty supervised clinical hours, including at least two psychotherapeutic treatment modalities. We'll now shift our focus to trends in the PMH APRN workforce. PMH APRNs contribute uniquely to a team by providing care that incorporates a holistic and comprehensive approach to treatment from a patient-centered perspective. Their provided services can include assessment, diagnosis, and psychotherapeutic and or pharmacological treatment. They also help to provide much-needed services to underserved populations that would otherwise have to be isolated and to populations that would otherwise have lack of access to mental health treatment. These data show PMH APRN workforce trends over time for both PMH CNSs and PMH NPs, including percentage of each prescribing over time and currently. According to this 2016 survey, there were nearly 16,000 certified PMH APRNs, the majority of whom have prescriptive authority. We know this number has continued to increase. And 64% of, of note, 64% of psych CNS and 96% of psych NPs are prescribing and 865 hold those certifications. These data from Dr. Mohler illustrate a comparison between PMH APRNs and psychiatrists in current numbers licensed, development of ongoing education and workforce, and patient population served. There are 19,000 licensed PMH APRNs now practicing in comparison to 25,000 licensed psychiatrists actively practicing. Graduates each year include 700 PMH NPs compared to 1300 psychiatric residents. Most PMH APRNs are practicing in rural and less populated urban areas versus psychiatrists practicing mostly in urban areas. These PMH NPs practicing in rural areas, as well as the 75% accepting both Medicare and Medicaid are certainly providing much needed mental health care in community and inpatient care. This is mostly to patients with serious mental illnesses. Working relationship between PMH APRNs and physicians varies from state to state. Many U.S. states require collaboration and supervision between APRN and physicians in order to practice, limiting scope of practice. The American Association of Nurse Practitioners maintains a map of state practice environment from full practice in green, restricted practice in yellow, and reduced practice in red. APRNs working as autonomous practitioners in states with full practice environment. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, as well as the National Council of State Boards of Nursing. These states are shown in green on the map. Examples include the District of Columbia, New Mexico, and Colorado. Some states with restricted practice environments fall in the middle range. APRNs are working to provide fairly independent care to individuals while still under some level of supervision or in collaboration with the physician. These states are shown in yellow on the map. Examples include New York, Pennsylvania, and Utah. Lastly, APRNs may be working under strict supervisory or in close collaboration relationships in states with reduced practice. These are the most restrictive practice environments, most limiting of the APRN scope of practice. These states are shown in red on the map. Examples include Texas, California, and Virginia. AANP continuously updates the state regulatory map, and it is available freely online even to non-members of AANP. Settings in which PMH APRNs work are listed here. As you can see, they are quite varied. Some examples of PMH APRN roles include combined psychotherapy and pharmacological management for patients, psychiatric assessment resulting in medication initiation and management in outpatient settings and inpatient settings like community clinicals, hospitals, long-term care facilities, and institutions such as jails, community-based care in which nurse practitioners are dispatched to members of the community that are experiencing mental health crises or are in need of expanded services. According to the American Psychiatric Nurses Association National PMH APRN Survey conducted in 2018, the top four categories in which PMH APRNs are working include ambulatory, inpatient, emergency, and long-term care settings in that order. Sixty percent of PMH APRNs work in ambulatory care. By definition, ambulatory care is any same-day medical and or psychiatric services performed in an outpatient setting. This refers to any service including diagnosis, observation, consultation, treatment, intervention, and rehabilitation services that is not performed in a hospital or a facility that requires admission. PMH APRNs work in ambulatory settings such as community mental health clinics, private practices, outpatient addiction treatment centers, shelters, and primary care practices that integrate medical and psychiatric treatment. Inpatient settings can include publicly or privately run psychiatric hospitals, medical hospitals with psychiatric units, forensic units for criminal offenders with serious mental illness, jails, and prisons. Emergency settings include settings in which PMH APRNs are addressing psychiatric needs in urgent care or emergency departments in areas designated for disaster relief medical assistance. Long-term care facilities include residential programs for drugs and alcohol, treatment, eating disorders, children and adults with serious mental illness, intellectual and developmental disabilities, skilled nursing facilities, and nursing homes for individuals with short-term or long-term physical mental health and or cognitive disabilities. Now that I've reviewed the evolution scope processes and settings in which PMH APRNs are currently working, I will end by outlining the specific types of services that PMH APRNs are currently providing. According to the 2018 APNA National PMH APRN Survey, the majority of PMH APRNs are providing psychoeducation, diagnostic evaluation, and medication management. 38% of PMH APRNs are providing psychotherapy services, most commonly cognitive behavior therapy and supportive psychotherapy.
Video Summary
In this video, Dr. Donna Rowland, a Clinical Associate Professor and Director of the Psychiatric Mental Health Nurse Practitioner Program at the University of Texas, discusses the evolving roles of Psychiatric Mental Health Advanced Practice Registered Nurses (PMH-APRNs). She begins by explaining the confusion and misunderstandings surrounding the various roles within the nursing discipline. She then provides an overview of the history and tradition of PMH-APRN roles, discussing the development of programs and certifications for PMH Clinical Nurse Specialists (CNS) and PMH Nurse Practitioners (NP). Dr. Rowland goes on to discuss the implementation of the LACE consensus model, which aimed to achieve consensus among various roles of APRNs. She explains the accreditation, education, licensure, and certification components of the model. Dr. Rowland also discusses the competencies and standards for PMH-APRNs, including the variety of psychotherapy content taught in educational programs. She explores the workforce trends and settings in which PMH-APRNs work, such as ambulatory care, inpatient settings, emergencies, and long-term care facilities. Finally, Dr. Rowland explains the specific services provided by PMH-APRNs, including psychoeducation, diagnostic evaluation, medication management, and psychotherapy.
Keywords
Psychiatric Mental Health Advanced Practice Registered Nurses
PMH-APRNs
LACE consensus model
PMH Clinical Nurse Specialists
PMH Nurse Practitioners
psychotherapy content
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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