The future of clinical nurse specialists in psychiatric-mental health nursing

The role of the clinical nurse specialist in psychiatric-mental health nursing is undergoing transformation secondary to massive changes occurring within the health care delivery system, as well as the larger society. In order to address these changes and their influence upon the evolution of the advanced practice role of clinical nurse specialists in psychiatric-mental health nursing, an Ad Hoc Committee consisting of twelve members of The Society of Certified Clinical Specialists in Psychiatric Nursing of the New Jersey State Nurses' Association met in 1996 and 1997 in order to explore and define the future of clinical nurse specialists in psychiatric-mental health nursing. This report is a summary of salient findings by the Committee which define numerous influences upon the role of psychiatric nurses in advanced practice, including factors affecting health care changes and influences of health care changes upon clinical nurse specialists in psychiatric-mental health nursing, along with recommendations for the future by members of the Ad Hoc Committee of the New Jersey Society of Certified Clinical Specialists in Psychiatric Nursing. The report is divided into three sections and is presented in three consecutive issues. Part Three is the final segment of this three part series. It contains the committee's final recommendations for the future.     

Barriers to practice and impact on care: an analysis of the psychiatric mental health nurse practitioner role

This paper is a retrospective review of the literature analyzing the role of the psychiatric mental health nurse practitioner in the community. Presented here is an appraisal of national and state mental health initiatives. Professional nursing regulations are reviewed, focusing on New York State advanced practice nursing. Barriers to practice are assessed with discussion on how barriers, such as statutory collaboration, impede access to treatment in the community for mentally ill psychiatric patients. The current New York State legislative agenda is featured. Clinical vignettes from a nurse practitioner's private community practice are presented to introduce and conclude how clinical practice barriers impede autonomous practice.     

Psychiatric nurse practitioner versus clinical nurse specialist: moving from debate to action on the future of advanced psychiatric nursing.

The psychiatric nursing literature recently has included a proliferation of discussions regarding the nature and direction of change impacting the future of advanced practice psychiatric nursing. The debate has focused most commonly on the role of the clinical nurse specialist versus the role of the nurse practitioner. The debate has produced little in the way of outcomes other than an entrenchment of positions. The stalemate in psychiatric nursing is producing a slow but steady surrender of the boundaries of psychiatric nursing to other fields of nursing. Although advanced practice psychiatric nurses disagree on what to become and what to be called, people with conditions such as depression, anxiety disorders, and other psychiatric disorders are being treated increasingly by family nurse practitioners. The time for debate has ended. Unless consensus regarding what constitutes the domain of psychiatric nursing is reached soon, the discussions will be moot because few clients will remain to be treated. This article began as a discussion between colleagues. The two authors teach at a regional state university, but they share diverse opinions regarding the substance and nature of advanced practice psychiatric nursing. These diverse views led to discussions that have implications not only for faculty practice, but for curricular design, and for decisions regarding how to best educate future nurses. The discussion developed into a presentation at the 20th Southeast Conference of Clinical Nurse Specialists. It was presented as a point-counterpoint discussion regarding this debate; one author advocated the perspective of traditional clinical nurse specialist and one advocated the perspective of a psychiatric nurse practitioner role. We conclude with a projected model of a merged role, with delineation of traditional clinical nurse specialist and nurse practitioner that must be blended for the new role.     

Implementing the clinical nurse specialist role in a regional state psychiatric hospital

Clinical nurse specialists (CNSs) are essential to enhancing psychiatric-mental health nursing within state psychiatric hospital settings. This article presents a project focused on the CNSs in a state psychiatric hospital to expand their clinical role to increase the quality of care to individuals with serious mental illness and their numbers in other state psychiatric hospitals. As the patient population served in these settings becomes more complex, it is critical that advanced practice nurses are provided with appropriate updated state-of-the-art advanced knowledge and skills to collaborate within the interdisciplinary team. Furthermore, because of the complexity of the client and systems characteristics, the CNSs' clinical leadership is critical to promote the best practices in direct care services as well as provide support to various levels of nursing through staff development and training, role modeling, and mentoring of new staff.     

Neonatal nurse practitioners--a model for expanding the boundaries of nursing culture in New Zealand

The development and terminology of what constitutes advanced practice nursing roles in New Zealand has been the subject of recent debate within nursing. This article outlines the development of the neonatal nurse practitioner role in New Zealand as an example of one advanced practice nursing role. A model of how nursing culture changes to include roles that incorporate components that historically have been considered the domain of other health professionals is proposed. This article outlines some of the issues surrounding the neonatal nurse practitioner role, including the educational requirements for this role in New Zealand.     

Perceptions of role functions of psychiatric nurse specialists

Specialized and advanced psychiatric nursing practice is an innovative concept in the health care service in Hong Kong. A clear definition of the role and practice of psychiatric clinical nurse specialists (CNS) is important for the development of expert psychiatric nursing practice but is still in a formative stage. A qualitative exploratory study was conducted to identify the psychiatric CNS's perceptions of their role and to compare their perceptions with those of their clinical psychiatric nurse colleagues. The main themes emerging from interviews, observations, and personal diary data were compared and condensed. Eight CNSs and 24 clinical nurse colleagues from acute care and community psychiatric nursing units voluntarily participated in the study. A four-component framework, including clinical practice, organization, education, and professional role, was adopted from nursing literature and used for categorization. The findings showed similarities of role perceptions in the clinical practice, organization, and education components between the CNSs and their nursing colleagues. Differences in role perceptions, concerns about inadequate knowledge and autonomy, and limitations in professional role are discussed.     

Awareness of self and expanding consciousness: using nursing theories to prepare nurse-therapists

Psychotherapy is an accepted role of the advanced practice psychiatric nurse. Nursing theorists, notably Hildegard Peplau and Margaret Newman, offer guidance on the psychological and professional development of the nurse. This paper examines Newman's theory of health as expanding consciousness and the concept of awareness of self in Peplau's theory, and suggests that psychiatric advanced practice nursing programs consider the need for nurses to develop self-knowledge to facilitate the nurse-patient relationship and to improve outcomes of patient care in psychotherapy.     

Delineating advanced practice nursing in New Zealand: a national survey

Background

A variety of advanced practice nursing roles and titles have proliferated in response to the changing demands of a population characterized by increasing age and chronic illness. Whilst similarly identified as advanced practice roles, they do not share a common practice profile, educational requirements or legislative direction. The lack of clarity limits comparative research that can inform policy and health service planning.

Aims

To identify advanced practice roles within nursing titles employed in New Zealand and practice differences between advanced practice and other roles.

Method

Replicating recent Australian research, 3255 registered nurses/nurse practitioners in New Zealand completed the amended Advanced Practice Delineation survey tool. The mean domain scores of the predominant advanced practice position were compared with those of other positions. Differences between groups were explored using one‐way ANOVA and post hoc between group comparisons.

Results

Four nursing position bands were identified: nurse practitioner, clinical nurse specialist, domain‐specific and registered nurse. Significant differences between the bands were found on many domain scores. The nurse practitioner and clinical nurse specialist bands had the most similar practice profiles, nurse practitioners being more involved in direct care and professional leadership.

Conclusions

Similar to the position of clinical nurse consultant in Australia, those practicing as clinical nurse specialists were deemed to reflect the threshold for advanced practice nursing. The results identified different practice patterns for the identified bands and distinguish the advanced practice nursing roles.

Implications for nursing policy

By replicating the Australian study of Gardener et al. (2016), this NZ paper extends the international data available to support more evidence‐based nursing workforce planning and policy development.     

The certified psychiatric nurse practitioner: advanced practice psychiatric nursing reclaimed

During the decade of the 1990s, health care reform, market forces, population needs, new knowledge in neuroscience and changes in advanced practice regulation provided the impetus for the development of the role of the psychiatric nurse practitioner. Debate about issues of role, scope of practice, educational preparation, titling, and credentialing for the advanced practice psychiatric nurse (APPN) of the future intensified as the American Nurses Credentialing Center (ANCC) proceeded with its controversial decision to develop a certification examination for the psychiatric nurse practitioner-in advance of consensus among advanced practice psychiatric nurses about those widely debated issues. Ironically, now that the ANCC adult and family psychiatric nurse practitioner (PMHNP) examinations exist, with test content outlines that clearly identify the professional standards and scope of practice relevant to the role of the certified psychiatric nurse practitioner, those contentious issues of role, scope of practice, educational preparation and credentialing (if not titling) seem considerably less thorny. In fact, by credentialing the role of the psychiatric nurse practitioner sooner rather than later, ANCC may have saved advanced practice psychiatric nursing for psychiatric nurses. This article proposes to (1). explain that assertion, (2). clarify what the scope of practice relevant to the newly certified role means in terms of credentialing requirements for existing types of psychiatric nurse practitioner, and (3). identify some of the controversies that linger with the debut of the PMHNP certification examination(s).     

Health assessment and its relationship to nursing practice in New Zealand

Health assessment has been an integral component of nursing education in Australia for over a decade. New Zealand has only recently embarked down this path and might benefit from the Australian experience. This article will discuss health assessment in the context of three issues currently topical in nursing in New Zealand. The issues are annual registration based on evidence of competence to practice, a review of undergraduate curricula, and the development of nurse practitioner/advanced nurse practitioner roles. The meaning of the concept 'health assessment' is also clarified in order to provide consistency as new initiatives in nursing are currently being developed.     

Role diversification in the education of advanced practice psychiatric nurses

The mode, location, and focus of health care services are changing rapidly, especially delivery of psychiatric services. The high prevalence of psychiatric and medical comorbidity, the national shift in health care to a managed care arrangement with one professional designated as principle provider, and problems with access to comprehensive services for individuals with psychiatric problems interact to create a compelling need for a clear definition of advanced psychiatric-mental health nursing practice. This article is, in part, a response to the national dialogue and debate sparked by the beginning development of a psychiatric nurse practitioner certification exam. However, this debate will be used merely as a starting point to articulate and document the need for a flexible, diverse, and evolving definition of advanced psychiatric-mental health nursing practice that can inform and shape educational programs in the discipline.     

Spasm or transformation? Advanced practice psychiatric nursing education in the United States

Psychiatric nursing graduate programs are in precipitous decline in the United States, leading many advanced practice psychiatric nurses to question the viability of their field. This article examines the current crisis in advanced practice psychiatric nursing education in the United States by identifying core concerns and exploring the reasons for these concerns. Suggestions for securing the future of this practice area are also discussed. These suggestions include identifying a more clearly focused role for advanced practice psychiatric nurses, development of realistic educational expectations, achievement of greater uniformity in curricula, and the establishment of a strong and rigorous process of accreditation.     

Integrating Informatics into the Graduate Community Health Nursing Curriculum

Abstract Advanced practice of community health nursing is enhanced if the nurse is able to identify, create, and use databases to support nursing assessments of communities and to manage and evaluate community health programs. The College of Nursing, Rutgers, The State University of New Jersey, has revised its curriculum for community health nursing graduate students to include a strong focus on nursing informatics. This paper summarizes the integration of theoretical content and practice exercises into a pre-course workshop and four-course sequence. A focal point of this effort has been the "Healthy People 2000 Nursing Informatics Project," in which students develop an automated community-assessment tool and database related to the Year 2000 objectives. The use of this database and related national, state, and local databases to document community needs is emphasized. Students also evaluate nursing information systems and use information technologies to design and evaluate community health grant proposals. Curriculum development, evaluation, and modification are detailed in relation to student learning needs, faculty preparation, and equipment and consultation requirements.     

Using mindfulness-based therapeutic interventions in psychiatric nursing practice--part I: Description and empirical support for mindfulness-based interventions

Finding effective nursing interventions for the treatment of mental illness is a major concern for advanced practice psychiatric nurses (APPN). Increasingly, innovative psychotherapeutic treatment modalities are being used for the treatment of individuals with serious mental illness. One such innovative approach, mindfulness-based therapeutic interventions, has been shown to relieve distress for individuals with medical and psychiatric illnesses. In part one of this two-part article, the investigators describe principle concepts of mindfulness, review current research in the usefulness of mindfulness practice for treatment of psychiatric illnesses, and outline the theoretical basis for this treatment modality, including mindfulness-based cognitive therapy (MBCT). In Part II, the writers detail the therapy phases of MBCT and present a clinical case in which an advance practice psychiatric nurse integrates mindfulness-based psychotherapeutic approaches into her treatment. This clinical case may inform future clinical nursing research and advanced psychiatric nursing practice.     

Shaping the advanced practice psychiatric-mental health nursing role: a futuristic model

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

SHAPING THE ADVANCED PRACTICE PSYCHIATRIC-MENTAL HEALTH NURSING ROLE: A FUTURISTIC MODEL

As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the specialty's capacity for innovation and the profession's capacity for new direction and futuristic change.     

The mental health nurse practitioner in the emergency department: an Australian experience

This paper describes the establishment of a mental health nurse practitioner (MHNP) position in New South Wales, Australia. The authors report on a MHNP role that functions collaboratively within a large inner city emergency department. Attention is centred on what constitutes advanced mental health nursing practice in the emergency department setting. Three areas associated with the work of MHNPs--therapeutic techniques, prescribing and care coordination and referral--are highlighted to explore the scope of the MHNP role. The authors propose that the success of this position is based on a process of consultation and evaluation, partnership between disciplines and clinical services and the role maintaining a truly nursing focus rather than attempting to replace or replicate psychiatric medicine.     

The clinical nurse specialist and nurse practitioner roles: room for both or take your pick?

OBJECTIVE: The aim of this paper is to contribute to pertinent discussions regarding advanced practice nursing roles. In particular discussion will focus on the potential implications for the developing nurse ractitioner (NP) role on the existing clinical nurse specialist (CNS) roles. SETTING: The literature presented originates primarily from the United States of America (USA), United Kingdom and Australia. Specific emphasis is placed on the psychiatric/mental health nursing context. PRIMARY ARGUMENT: Amidst the confusion in terminology to describe and explain advanced, expanded or extended nursing roles, and to distinguish between the clinical nurse specialist and the nurse practitioner, there is a need to establish clarity. The need for both clinical nurse specialist and nurse practitioner roles has been hotly debated in the USA. CONCLUSIONS: The roles of clinical nurse specialist and nurse practitioner may be complementary but fulfil different functions. It is therefore important that both roles be maintained and implemented in response to consumer and health service needs.     

Advanced psychiatric nursing education in Britain

This paper examines the British provision for advanced education in psychiatric nursing. Information was derived from a review of the literature, personal contacts with nurse educationalists, and an undergraduate project supervized by the author. After operationally defining advanced education, the paper describes courses at pre- and post-registration levels. These include degree, diploma, clinical, educational and managerial courses. The psychiatric component of nursing degree courses is also considered. Current provision is critically discussed and compared with similar courses for general nurses and educational provision abroad. The paper analyses how and why the current situation has occurred and the effects of current provision on psychiatric nursing practice. The paper concludes with proposals for future developments. These include recommendations for higher education based courses and consideration of a single register of nurses.