Essential educational content for advanced practice in psychiatric consultation liaison nursing

Essential Educational Content for Advanced Practice in Psychiatric Consultation Liaison Nursing Pamela A. Minarik and Jane B. Neese Psychiatric Consultation Liaison Nursing (PCLN), an advanced practice subspecialty of psychiatric mental health nursing, has evolved over the last 4 decades in response to increased recognition of the importance of psychophysiological interrelationships and their impact on wellness, physical illness, and recovery. PCLN specialists practice in many countries although there are few PCLN programs in schools of nursing. This article defines PCLN, reviews its history, and recommends essential educational content for inclusion in a master’s curriculum to prepare graduates for competent and effective PCLN practice. The educational content is based on the work of the PCLN Core Curriculum Task Force of the International Society of Psychiatric Consultation Liaison Nurses and is integrated with the 1990 Standards of Psychiatric Consultation Liaison Nursing Practice and the 2000 Standards of Psychiatric-Mental Health Nursing Practice. The relationship of the PCLN educational content to other national curriculum guidelines is discussed in the proposed PCLN curriculum content. Copyright © 2002 by W.B. Saunders Company

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SYCHIATRIC CONSULTATION Liaison Nursing (PCLN), a recognized advanced practice subspecialty of psychiatric mental health nursing, has evolved over 4 decades in response to recognition of the importance of psychophysiological interrelationships and their impact on wellness, physical illness, and recovery (American Nurses Association (ANA), 2000; Krupnick, 1995; Kurlowicz, 1998). Increasingly, the psychiatric nursing community has emphasized the interplay of the mind and body in wellness and illness in the context of an explosion in neurobiological knowledge (McBride & Austin, 1996). The purpose of this report is to recommend essential educational content for PCLN within a master’s level psychiatric nursing curriculum consistent with the 1990 Standards of Psychiatric Consultation-Liaison Nursing Practice (ANA, 1990) and the 2000 Scope and Standards of Psychiatric-Mental Health Nursing Practice (ANA, 2000). Because of the dramatic changes in health care delivery affecting all settings, practice such as PCLN that integrates the psychiatric, psychosocial,

and physical aspects of care in a systems approach is essential. PCLN specialists make psychiatric and psychosocial diagnoses and implement a variety of direct and indirect care interventions with physically ill or disabled clients and their families. PCLN skills, such as collaboration and consultation with consumers and nonpsychiatric members of the health care team, are crucial in today’s health care settings. Skillful systems intervention is indispensable as health care becomes more of a

From the School of Nursing, Yale University, New Haven, CT, Professor, Aomori University of Health and Welfare, Aomori, Japan and the College of Nursing and Health Professions, University of North Carolina at Charlotte, Charlotte, NC. The opinions expressed in this article are those of the authors and do not necessarily reflect the views of the agencies. Address reprint requests to Pamela Minarik, RN, MS, FAAN, Aomori University of Health and Welfare, 58-1 Mase, Hamadate, Aomori-shi, Aomori, 030-8505 Japan. E-mail: [email protected] Copyright 䊚 2002 by W.B. Saunders Company 0883-9417/02/1601-0002$35.00/0 doi:10.1053/apnu.2002.30495

Archives of Psychiatric Nursing, Vol. XVI, No. 1 (February), 2002: pp 3-15

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business with financial pressures, downsizing of staff and facilities, higher proportions of complex patients, shortened length of inpatient stay, and growing nurse dissatisfaction with the work environment resulting in an ominous nursing shortage. Consumers are frustrated about lack of staff and perceived decrease in quality care. Health care providers are frustrated about limited human and fiscal resources to provide quality care, thus creating a chaotic, angry, litigious environment. In these circumstances, PCLN specialists provide a needed expert psychiatric resource for patients, their families, staff and administrators, thus educational preparation for this role is vital. The PCLN subspecialty is at a pivotal point experiencing strong pressures to respond to the needs of the relational and systems context of patient care, and at the same time, strong pressure to emphasize primarily direct care in collaboration with or independent of the limited numbers of consultation liaison psychiatrists. The prevalence of psychiatric and medical comorbidity is increasingly recognized. However, psychiatric problems often are unrecognized and untreated in nonpsychiatric settings. Many of these problems are chronic, associated with significant disability, and increased use of health care services, especially among individuals with chronic medical conditions (Katon, von Korff, Lin, Bush, et al., 1990; Kessler, McGonagle, Zhao, Nelson, et al., 1994; Ormel & Oldehinkel, 1993; Pasacreta, Minarik, Cataldo, Muller & Scahill, 1999; VonKorff, Ormel, Katon & Lin, 1990). PCLN practice occurs in nonpsychiatric pediatric, adult, and geriatric settings, such as hospitals, extended care facilities, rehabilitation centers, home care and visiting nurse agencies, primary and specialty care ambulatory clinics, health maintenance organizations, managed care networks, and private practices. The client may be anyone involved in the situation, from the person with actual or potential physiological dysfunction and/or their families, to the nurses and other clinicians, or the health care system itself. Cotroneo, Outlaw, King, and Brince (1997) describe integrated primary health care as “a biopsychosocial approach that emphasizes the relational, contextual nature of health care, viewing mental health care as instrumental in prevention, health promotion, and the treatment of acute, episodic, and chronic illness” (p. 27). This could be a description of PCLN. The PCLN role integrates

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the medical and psychiatric aspects of care and thus is the forerunner of the blended clinical nurse specialist (CNS) and nurse practitioner (NP) role in psychiatric mental health. Although interest in PCLN practice continues, notably outside the U.S., current guidelines for education are lacking. There are few identified PCLN programs in schools of nursing although health care organizations continue to seek and employ PCLN specialists. The current Standards of Psychiatric-Mental Health Nursing Practice (ANA, 2000) guide all of psychiatric mental health nursing practice and incorporate PCLN practice but with less specificity than the original Standards of Psychiatric Consultation Liaison Nursing Practice (ANA, 1990). Although the current number is unknown, PCLN specialists currently practice in the United States, Canada, England, Scotland, Japan, the Netherlands, New Zealand, and Australia (Brendon & Reet, 2000; Egan-Morriss, Morriss & House, 1994; Newton, 1999; Nozue, 1999; Roberts, 1997; Sharrock & Happell, 2000; Tunmore & Thomas, 1992; Zandstra, 1998). Identifying a need for PCLN practice, nurses in other countries have requested information from PCLN specialists in the U.S. about a curriculum specifically addressing PCLN education and practice. HISTORICAL OVERVIEW

Billings (1939) who was a faculty member of the newly developed Psychiatric Liaison Department in Colorado first used the term liaison psychiatry. Liaison psychiatry began to flourish in the 1950s and the 1960s (Robinson, 1974) and psychiatric liaison nursing soon followed with the first published cross-service consultation at Duke University in 1963 (Johnson, 1963). Ten years later, the first two graduate programs in psychiatric liaison nursing were offered at the University of Maryland (1972) and Yale University (1974) (Bryant, 1983; Nelson & Davis, 1979; Robinson, 1972). In the 1970s, the first psychiatric liaison textbooks by Dr. Lisa Robinson (1974; 1978) were published along with the first psychiatric liaison nursing research article authored by Barbara Wolfe (1978). Also published were articles addressing the role and practice (Barton & Kelso, 1971; Berarducci, Blandford & Garant, 1979; Davis & Nelson, 1978; Nelson & Schilke, 1976). In the next decade, a second textbook about psychiatric liaison nursing (Lewis & Levy, 1982)

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was published. Journal articles continued to examine the role and functions of the psychiatric liaison nurse (Barbiasz, Blandford, Byrne, Horvath, Levy, et al., 1982; Dulaney & Crawford, 1988; Lipowski, 1981; Minarik, 1984; Robinson, 1982; 1987; Stickney & Hall, 1981), and began to address population or intervention specific practice, evaluation methods, and research (Campinha-Bacote, 1988; Grant 1988; Pasacreta & Massie, 1990). As a subspecialty, the practice evolved from a focus on patient- and consultee-centered consultation, to direct care of the patient, then to organizational team building, and later to evidence-based practice. At the first psychiatric liaison nursing national conference in 1987, the Psychiatric Liaison Nursing Special Interest Group was created and affiliated with the ANA, Council of Psychiatric Mental Health Nursing. After the Psychiatric Liaison Nursing Special Interest group developed the Standards of Psychiatric Consultation Liaison Nursing Practice (ANA, 1990), the subspecialty was officially recognized as distinct (Neese, 1996). With growth in membership and attendance at the annual conference and the concomitant divestiture of specialty interest councils within the ANA structure, the International Society of Psychiatric Consultation Liaison Nurses (ISPCLN) was formed as a freestanding organization. During the 1990s, psychiatric consultation liaison nurses began to subspecialize (Moschler & Fincannon, 1992). Publications within the discipline continued to address roles and functions (Chase, Gage, Bonadonna, & Stanley, 2000; Shahinpour, Hollinger-Smith, & Perlia, 1995, Santmyer & Roca, 1991). Publications expanded to include research, organizational consultations, illness-specific interventions, outcomes of those interventions, and methods of evaluating the role (Baldwin, 1993; Chase & Stuart, 1995; Chisholm, 1991; Federici & Tommasini, 1992; Hart, 1990; Inaba-Roland & Maricle, 1992; Minarik, 1995; Neese, 1991; Nield-Anderson & Clarke, 1996; Santmyer, Serafini & Larson, 1992; Stanley, 1999; Titlebaum, Hart, & Romano-Egan, 1992). In 1998, ISPCLN joined with the Association of Child and Adolescent Psychiatric Nursing (ACAPN) and Society for Education and Research in Psychiatric Nursing (SERPN) to create the International Society of Psychiatric-Mental Health Nurses (ISPN).

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DEFINITION AND CHARACTERISTICS OF PCLN PRACTICE

A PCLN specialist is an advanced practice registered nurse in psychiatric-mental health (APRNPMH) who is educationally prepared at the master’s level in the specialty of psychiatric mental health nursing (ANA, 2000). The graduate preparation is distinguished by an in-depth knowledge of theory and practice, validated clinical experience, and competence in advanced clinical nursing skills (ANA, 2000). National certification in psychiatric nursing is recommended (ANA, l990). A PCLN specialist may be certified in another subspecialty such as oncology. PCLN specialists generally function independently in a staff or consultative position rather than a line or administrative position. In addition to knowledge and clinical expertise, attributes necessary for successful PCLN practice include accessibility, flexibility, objectivity, creativity, resilience, patience, leadership ability, excellent interpersonal skills, and personal and professional maturity (Lewis & Levy, 1982; Kurlowicz, 1998). Useful characteristics are acceptance of ambiguity, tolerance of personal rejection, and the capacity and willingness to tolerate stressful and often unpredictable “difficult” situations with clients, families, and health care providers (Krupnick, 1995; Kurlowicz, 1998; Nield Anderson, Minarik, Dilworth, Jones, et al., 1999; Robinette, 1996). Previous clinical experience in both psychiatric and medical-surgical nursing is recommended (Lewis & Levy, 1982; Kurlowicz, 1998). Administrative nursing experience can also enhance the PCLN specialist’s knowledge of consultees and health care organizations (Kurlowicz, 1998). Direct Care PCLN specialists provide direct care psychiatric mental health nursing services that emphasize coping responses to acute, catastrophic, and potential physical dysfunction, identification of undiagnosed psychiatric disorder in people with physical illness, and preventive care to decrease the effects of distress and mental disorder (ANA, 1990; 2000). PCLN practice focuses on the impact of the patient’s psychological state and environmental context on his/her physical state and ability to participate in treatment. Additionally, PCLN practice involves the identification of behavioral, emotional, and cognitive expressions of pathological

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physical states and collaboration with other disciplines in diagnosis, intervention, and evaluation (ANA, 1990, Kurlowicz, 1998). An individual PCLN specialist may emphasize either direct or indirect care or both. Consultation and Liaison Activities PCLN practice includes indirect care, consultation and liaison activities (ANA, l990; Kurlowicz, 1998). Kurlowicz (1998) describes consultation and liaison activities as complementary, interdependent, and inseparable in clinical practice. Mental health consultation is an interactive process between a consultant, who is selected for specific expertise and a consultee, who is seeking help or advice about a patient-related, staff-member-related, or organizational system problem (Caplan, 1970; Kurlowicz, 1998). A PCLN consultation is often requested when the problem is unclear; frequently, there is a discrepancy between an identified and actual problem. Much expertise is required to recognize this phenomenon. PCLN specialists use a process of “diagnosing the total consultation” (Lewis & Levy, 1982, p. 18). When diagnosing the total consultation, the family system, the medical illness and medical record are assessed as well as caregiving system data including the source and timing of the consultation request, the knowledge, attitudes, and skills of the consultee, consultee’s milieu, roles and relationships between caregivers, leadership patterns and administrative support, and the relationship of the PCLN specialist with the consultee (ANA, 1990). The PCLN diagnoses the problem, whether patient-related, staff-related and/or system-related, and develops the interventions needed to resolve the diagnosed consultation problem (Lewis & Levy, 1982). Intervention remains in the domain of the consultee; thus allowing the possibility for the PCLN specialist to work with individuals at any level in the system (Caplan, 1970; Kurlowicz, 1998). Differing from other advanced nursing practice roles, PCLN work varies in response to the particulars of each request and situation. More than ever before, the rapidly changing health care system and increasing complexity of patient problems creates a compelling need for this unique and flexible role. The word liaison in PCLN refers to the linkage of the knowledge base of psychiatric-mental health nursing and the care of clients or families with

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actual or potential physical dysfunction in a diversity of health care settings (ANA, 1990). The liaison process enhances the therapeutic qualities of the care environment and also can be seen as the linkage of health care professionals to facilitate communication, collaboration, and building of partnerships between clients and health care providers (Kurlowicz, 1998; Robinson, 1987). Liaison activities include unit-based nursing education programs, patient education programs, participation in discharge planning, nursing care planning, and/or health care team rounds, patient care conferences, and facilitation of patient, family, or staff nurse support groups (Krupnick, 1995, Kurlowicz, 1998). Examples of systems interventions include staff team building or strategic planning retreats, group facilitation/group process consultation for performance improvement groups, staff conflict mediation, and administrative coaching. Support for nursing staff to help them cope with stressful and difficult situations, intervene appropriately with distressed patients and families, and make effective systems changes is a key liaison activity. FRAMEWORK FOR THE PCLN CURRICULUM

An interactive relationship exists between education and practice. Curricula for master’s education in nursing are based on guidelines delineating: (1) essential content for all master’s educated nurses; (2) the essential core content for all advanced practice nurses in direct care roles; (3) essential content for the specialty and; (4) essential content for the subspecialty. Figure 1 illustrates the relationship of the PCLN content to core curriculum content for all master’s degree students, for all advanced practice nursing students, and for all psychiatric mental health nursing students. The PCLN content and the content individualized to the clinical site are built on the foundation of the other content. Based on the delineated guidelines, curricula prepare advanced practice nurses for practice. Both education and practice are informed by research. Practice is guided by scope and standards of nursing practice developed by the professional and specialty organizations. Standards of practice apply to professional nursing activities shown by the nurse through the nursing process, which is the base of clinical decision-making (ANA, 2000). Standards of practice, research, educational guidelines, curricula, and practice are continually in an

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Fig 1. Curriculum for PCLN. Adapted with permission from Sparacino, P.S.A. (1994). Issues and future trends for the critical care clinical nurse specialist. In A. Gawlinski & L.S. Kern (Eds) : The clinical nurse specialist role in critical care : American Association of Critical Care Nurses. Philadelphia : W.B. Saunders, p. 300.

evolving process, influencing each other (see Fig 2). The essential content for master’s education in nursing and the core content for all advanced clinical practice students is defined by the American Association of Colleges of Nursing (AACN) in The Essential Elements of Master’s Education for Advanced Practice Nursing (see Table 1 for summary.) Additional educational content for CNSs, missing from the essential elements delineated by AACN, was defined by the National Association of Clinical Nurse Specialists (NACNS) (Lyon, Davidson, Beecroft, Bingle, Dayhoff, & Ellstrom,

1998) (see Table 2). Built on this foundation is psychiatric mental health nursing content defined by SERPN (1996) (see Table 3). The essential educational content presented in this paper is specific to the subspecialty of PCLN and is based on the work of the ISPCLN Core Curriculum Task Force (1992-1996). It builds on the foundations provided in the documents by AACN (1996), NACNS (Lyon et al. 1998), and SERPN (1996) and is guided by the standards of practice developed by the ANA (1990; 1996; 2000). These content recommendations, in addition to being useful for integration into master’s programs, will be

Fig 2. Interactive relationship between standards of practice, curriculum guidelines and PCLN practice, education, and research.

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Table 1. Essential Elements of Master’s Education for Advanced Practice Nursing Graduate Core Curriculum Content I. Research II. Policy, Organization, and Financing of Health Care A. Health care policy B. Organization of the health care delivery system C. Health care financing III. Ethics IV. Professional Role Development V. Theoretical Foundations of Nursing Practice VI. Human Diversity and Social Issues VII. Health Promotion and Disease Prevention Advanced Practice Nursing Core Curriculum I. Advanced Health/Physical Assessment II. Advanced Physiology and Pathology III. Advanced Pharmacology Reprinted with permission from The essentials of master’s education for advanced practice nursing by American Association of Colleges of Nursing, 1997, p. 5.

valuable as a guide for individual continuing professional development. PCLN ESSENTIAL EDUCATIONAL CONTENT

The PCLN standards of 1990 were based on the standards then current, the 1986 standards of psychiatric nursing (ANA, 1986). The PCLN standards (ANA, 1990) are of both historic and contemporary importance as they are the only guidelines specifically delineating the practice of PCLN and continue to be part of the legacy and role of PCLN specialists. The authors do not intend by the use of the 1990 PCLN standards to negate the current standards of psychiatric-mental health nursing (ANA, 2000). Described in relation to the 1990 and the 2000 standards, the PCLN essential educational content defines the subspecialty content for didactic and clinical experiences. Didactic Content Didactic content is summarized in Table 4. The 1990 standards and the current 2000 standards document the theoretical basis of the subspecialty as the synthesis and application of models and research in nursing, psychiatry, biology, psychology, sociology, including systems theory, consultation theory, crisis intervention, and adult learning theory. Specific and central to PCLN is theory describing stress, coping, and adaptation. Central concepts include (1) health and illness behavior, including the range of normal to pathological or

maladaptive responses to physical conditions; (2) patterns of responses including uncertainty, anger, grief and loss to stressors such as developmental and situational losses, illness onset and hospitalization, death and dying; (3) pain and pain management, (4) mind/body connection, psychoneuroimmunology (Kiecolt-Glaser & Glaser, 1986); and (5) levels of prevention (primary, secondary, and tertiary) (ISPCLN Core Curriculum Task Force, 1992-1996, Kurlowizc, 1998). The influence of culture on health and illness behavior is essential. Evidence-based practice is highlighted (Slinger, 2001). Theories of organizational behavior, principles of power and influence, and change theories provide an important foundation for PCLN practice. Content on the state of knowledge regarding PCLN is important. This content includes the historical development of the specialty (Lewis & Levy, 1982; Robinson, 1968; 1972; 1978; 1982; 1987); ANA Standards for PCLN (1990; 2000); role functions (Kurlowicz, 1991, Van Fleet & Hughes, 1996), research on the role (Davis & Nelson, 1980; Fincannon, 1995; Mallory, Lyons, Scherubel, & Reichelt, 1993; Stickney, Moir, & Gardner, 1981; Wolfe, 1978), research utilization (Kane & Kurlowizc, 1994), cost-effectiveness and outcomes of PCLN practice (Kurlowizc, 2001; Newton & Wilson, 1990; Talley, Davis, Goiciecha, Brown, & Barber, 1990; Tommasini, 1992), and financing of practice (Platt-Koch, Gold, & Jacobsma, 1990). References previously identified in this report also would be appropriate. Essential to include are PCLN outcome research, and evidencebased interventions effective with the medically ill

Table 2. Critical Educational Content for CNS Practice Missing From AACN’s Essentials 1. Differential diagnosis and treatment of symptoms, functional problems, or risk behaviors with nondiseasebased etiologies 2. A scientific base for the deliberate selection and use of specific nursing interventions 3. Clinical inquiry 4. Evaluation and measurement methodologies 5. Selection, design, and use of technology/products/devices 6. Change/influence theory Data from Lyon, Davidson, Beecroft, Bingle, Dayhoff, Ellstrom (1998). National Association of Clinical Nurse Specialists Statement on clinical nurse specialist education and practice. Glenview, IL: NACNS, p. 11.

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Table 3. Essential Content for Graduate Education in Psychiatric Mental Health Nursing (PMHN) 1. Theories related to the neurobiological aspects of mental illness, developmental theories and models, psychotherapy theories and models 2. Assessment of community mental health needs, ethnic and cultural aspects of accessing and collaborating with specific populations for mental health care, traditional and nontraditional community practice sites, emerging service delivery models 3. Diagnostic characteristics of specific psychiatric illnesses, risk factors associated with psychiatric illnesses, prevention and mental health promotion 4. Collaboration, psychoeducation 5. Comprehensive psychiatric mental health history, psychiatric interviewing, diagnostic classification systems related to psychiatric illness, psychiatric formulations underlying treatment plans, psychotherapeutic treatment modalities, PMH Consultation/Liaison theory, clinical supervision, clinical case management, boundary issues related to direct and indirect advanced practice, primary psychiatric care as a first line provider 6. Psychopharmacology 7. Differential diagnosis 8. Comprehensive psychiatric assessment, diagnosis of common physical illnesses that mimic psychiatric illnesses and common psychiatric symptoms that occur in physical illness 9. Advanced PMHN certification and licensure (e.g. Nurse Practice Act; Standards for Advanced PMHN), forensic issues (e.g. prediction of violence, duty to warn), boundary issues related to direct and indirect PMHN practice, confidentiality and its limits, informed consent, contracting for service provision 10. History of mental health legislation, mental health policy practice implications, mental health policy and social climate 11. Fiscal consequences of public policy on mental health service delivery, principles of behavioral health care, cost benefit analysis related to psychiatric services, contracting with healthcare providers 12. Intervention research related to psychiatric treatment, outcomes research related to psychiatric treatment 13. Knowledge of mental health consumer/advocacy groups, functions of advisory boards Adapted with permission from Educational preparation for psychiatric-mental health nursing practice. Society for Education and Research in Psychiatric-Mental Health Nursing (SERPN), 1996, p. 45-50.

(Brooten & Naylor, 1995, Gurka, 1991, Kurlowizc, 1994, Naylor & Brooten, 1993, Wu, Crosby, & Ventura, 1994). Consistent with both 1990 and 2000 standards and similar to other APRN-PMHs, PCLN students

need to learn how to conduct a comprehensive psychiatric assessment including interviewing, history-taking, mental status assessment, and health assessment, as well as a family interview and assessment.

Table 4. Didactic and Clinical Content for the PCLN Student I.

II.

III.

IV.

V.

Synthesis and Application of Theories: nursing, psychiatry, neurobiology, psychology, sociology; systems theories; consultation theories and models; crisis intervention; adult learning theories; stress, coping and adaptation; health and illness behavior including influence of culture; response patterns to stressors; pain and pain management; mind/body connection and psychoneuroimmunology; levels of prevention; theories of organizational behavior, change theories. Psychopathology, Diagnostic Formulation, and Treatment: psychopathology, diagnostic classification systems, psychiatric assessment including interview and history-taking, mental status assessment, health assessment, family interview and assessment, psychiatric and psychosocial problems related to major physical illnesses, psychiatric disorders common in the physically ill, physical illnesses that mimic psychiatric disorders, psychotherapeutic treatment models, brief treatment modalities, health teaching. Pharmacology: neuroanatomy and physiology, psychopharmacology (antidepressants, anxiolytics, antipsychotics, atypical antipsychotics, benzodiapines, and anticonvulsants), laboratory and diagnostic tests, psychopharmacology in the physically ill, laws governing prescriptive practice Psychiatric Consultation Liaison Nursing: history, standards, role functions, research, cost-effectiveness and outcomes, evidence-based interventions with the medically ill, consultation role and models, liaison roles, system assessment and intervention, community mental health assessment, group psychotherapy and its relationship to work groups and physically ill patient groups, and mental health policy. Clinical Experiences: advanced psychiatric nursing skill development and judgment: mental status and health assessment; practice of psychopharmacology; implementation of psychotherapeutic interventions; direct patient and family care in nonpsychiatric setting; collaboration with health care team, clinical supervision, consultation and liaison experiences, educator experiences.

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Both the 1990 and 2000 standards emphasize the derivation of diagnoses from comprehensive assessment data and the use of accepted classification systems. Essential PCLN content includes the major classification systems (DSM, ICD, NANDA), identification of psychiatric and psychosocial problems, and patterns of responses of patients and families related to the major causes of death (heart disease, cancer, HIV, accidents, trauma), chronic illness, and dying. Also essential is knowledge of physical disorders that mimic psychiatric symptoms, somatoform and factitious disorders, and psychiatric disorders, such as depression, delirium, dementia, anxiety, substance abuse, and posttraumatic stress disorder that occur commonly in the physically ill. In the 2000 standards, the focus is primarily on the patient. Identification of expected outcomes are individualized to the patient, planning for care is negotiated among the patient, nurse, family, and health care team, and the prescription of evidence-based interventions to attain expected outcomes is elaborated (ANA, 2000). Essential content includes nursing (Bulechek & McCloskey, 1992) and psychiatric mental health therapeutics. In the PCLN didactic content, planning care and interventions are taught as collaborative in nature and include intervention and resolution of systems problems, a defining feature of PCLN practice. A systems assessment, including aspects of the “total consultation,” is unique to PCLN practice. PCLN liaison and consultation activities emphasize the importance of learning to collaborate with the consultee in the assessment of the client/family and the caregiving system (for illustration, see Minarik & Sparacino, 1990). Educational content emphasizes the boundary between psychiatric, medical and surgical care, and technology. Essential PCLN content, therefore, includes systems theories and principles with application to the identification of sources of system dysfunction that interfere with care; and organizational interventions, such as organizational change programs (ISPCLN, 1997). Educational content on the advanced practice role of the consultant is essential as this is a more prominent feature of PCLN in comparison to other APRN-PMH roles (Barron & White, 2000). Content includes consultation theory, the role of the consultant and the consultee, models of consultation, communication, and interviewing skills ap-

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propriate to a variety of circumstances, and problem-solving skills (Norwood, 1998; Patterson, Strumpf, & Evans, 1995; Sperry, 1996). Similar to other APRN-PMH roles, knowledge of different types of interventions is essential content, including individual, group, and family psychotherapy models, short-term cognitive/behavioral treatments, mind/body techniques such as hypnotherapy, relaxation and guided imagery (Zahourek, 1985), group treatments, and principles of milieu management applied to the nonpsychiatric setting (Robinette, 1997). Health teaching, anticipatory guidance and psychoeducation as applied in the nonpsychiatric setting, group work with nurses, and family nursing interventions (Ragaisis, 1994) should be addressed. Prescriptive authority was not included in the 1990 PCLN standards, but the 2000 standards (ANA, 2000) explicitly include prescriptive authority and treatment (ANA, 2000). The APRNPMH uses “prescriptive authority, procedures, and treatments in accordance with state and federal laws and regulations, to treat symptoms of psychiatric illness and improve functional health status” (ANA, 2000, p. 39) relate to this standard. Therefore, educational content for all advanced practice psychiatric mental health nurses includes psychopathology, neuroanatomy and physiology, psychopharmacology, alcohol and drug abuse, toxicity, and withdrawal, pain management, pharmacological management of agitated behavior, laboratory values, and diagnostic tests. The Psychiatric Mental Health Nursing Psychopharmacology Project (ANA, 1994) documents the necessity of inclusion of neuroanatomy and neurophysiology in conjunction with the clinical management of psychopharmacology. Federal and state laws governing advanced nursing practice and prescriptive authority (Hales, Karshmer, Motes-Sandoval, & Fiszbein, 1998; Kaas & Markley, 1998; in review; Lyon & Minarik (2001); Pearson, 2000) should be addressed within any graduate curriculum. Specific to PCLN education and practice are the use of psychopharmacologic agents in the physically ill and the interaction of these agents in acute illness or acute exacerbation of chronic illnesses. Clinical Content Clinical content (see Table 4) can be divided into two parts; each tailored to the student’s preexisting individual skills, knowledge, and experi-

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ence. During the first year, clinical experiences for all PMH graduate students focus on advanced psychiatric nursing skill development and judgment, especially those related to assessment, psychopharmacology practice, and psychotherapeutic skills. In the final clinical course the focus is on the PCLN role, with an emphasis on organizational skills; effective integration of consultation, education, and leadership with the direct care component; and clinical supervision for training purposes, management of consultative dilemmas (Kurlowicz, 1998), and management of exposure to traumatic events. Because ideal expectations of practice may be incongruent with clinical realities and require goal adjustment, a PCLN specialist preceptor for the graduate nursing student is key. Building on the foundation of all prior didactic and clinical courses, the direct care component in the residency includes the application, in a nonpsychiatric setting, of advanced practice nursing clinical skills and judgement to the care of clients and/or their families, who are struggling to cope with the stresses imposed by physical health problems and who may or may not identify themselves as having a mental disorder (for illustrative clinical vignettes, see Kane & Warner, 1999). Direct care experiences optimally include brief psychotherapy, crisis intervention, group work, psychoeducation, other appropriate treatment modalities, and referral to community services. Prescriptive practice may be included if appropriate in the setting. Family care involves applying appropriate family therapy intervention techniques to address the family’s presenting problem and coaching the patient/family to navigate the organization and get their needs met in a complex healthcare system. Experience in collaboration with patients, families, and other members of the health care team, including the liaison psychiatry team, in the formulation and implementation of plans of care is necessary. Based on experiences providing direct care, the student then develops skills in the indirect care roles of consultant, educator, leader, and researcher. Thus, students gain supervised experience in the initiation, maintenance, evaluation and termination of consultations incorporating both direct and indirect intervention strategies, including group work with nurses. The student integrates direct clinical practice, consultation, liaison, teaching, research, and leadership as a novice PCLN specialist in a particular nonpsychiatric clinical

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setting. Emphasis in the student’s clinical experiences is on the consultative and liaison relationships within the organization with consultees for whom psychiatric terminology may be unfamiliar. This content differentiates the PCLN specialist from other APRN-PMHs. Clinical application of models of consultation, systems theories and principles, communication and interviewing skills, and problem-solving skills are all part of the clinical experiences. Clinical experiences optimally include consultee-centered and program-centered administrative consultation (Baldwin, 1993; Chase & Stuart, 1995; Minarik & Catrambone, 1993). Student clinical experiences should include the role of educator. Education of other health care providers is a significant part of PCLN practice because of the importance of integrating psychiatric mental health principles and practice into nonpsychiatric care. Recognizing the influence of organizational structures and systems issues on service delivery, PCLN specialists focus on educating clinical and administrative staff about strategies for dealing with difficult patients and difficult situations with the goal of providing the highest quality of care possible. Clinical experiences assist the student in applying adult learning theory and examining organizational as well as community resources in nonpsychiatric settings. CONCLUSION

With patients spending less time in traditional inpatient psychiatric and medical facilities in combination with an aging population and increased comorbidity of chronic physical health and psychiatric problems, the need for PCLN practice continues to grow. Psychiatric nursing care is being delivered in diverse settings. Given that psychiatricmental health practice has been influenced by an explosion in neurobiological knowledge and recognition of the mind/body connection, consultation and collaboration with consumers and nonpsychiatric members of the health care team increasingly is emphasized. These are all strengths of PCLN. Ideally, PCLN educational content is included in all psychiatric mental health graduate programs, optimally in a separate track. With decreasing economic resources in higher education, increasing PLCN concentrations throughout the country seems unlikely; however, incorporating portions of the curriculum content into existing graduate psychiatric programs could benefit those graduates

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who ultimately will work in psychiatric consultation liaison nursing. The authors hope that schools of nursing will ensure that the content described here is included in psychiatric-mental health graduate programs. For those schools of nursing that have a PCLN track or concentration in their programs, this article provides a guide for ensuring PCLN educational content that is consistent with national standards and other national guidelines for graduate curricula. ACKNOWLEDGMENT For their significant contributions to the development of the essential educational content, the authors wish to acknowledge the members of the ISPCLN Core Curriculum Task Force (1992-1996): Linda Armstrong, Susan Krupnick, Deanna Pearlmutter, Lisa Robinson, Celeste Shawler, Nancy Tommasini, Penelope Chase, Linda Cook, Jane Gersmeyer, Jim Kane, and Lee Anne Xippolitos. The authors thank Jeannie Pasacreta and Leslie Nield-Anderson for their thoughtful review and recommendations. For their enthusiasm, numerous reviews, and many recommendations, the authors are indebted to Peggy Dulaney and Lenore Kurlowicz.

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