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Surrounded by banana peels: Is psychiatric nursing slipping?
Journal o f the American Psychiatric Nurses Association
Point o f View Surrounded by Banana Peels: Is Psychiatric Nursing Slipping?. Sandra Thomas, RN, PhD, FAAN
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a caseload of 2000 patients. I see 50 to per day in medication clinic. They get no teaching, no therapy." "I need a physician to sign off on my prescriptions every 3 months. One doctor I approached about doing this wanted 50% of my salary to do it." "Family nurse practitioners are flooding the market. They don't know an antipsychotic from an antidepressant, but they are allowed full prescription privileges." "Psych specialists are a dying breed. I look with nostalgia at my practice in the 1980s." These are the voices of psychiatric clinical specialists venting their anger and discouragement in the turbulent, waning years of the 20th century. Some are longing for the past rather than gearing up for the future. They are remembering the once-proud specialty that pioneered national certification and development of standards for specialty practice. They are worried, and so am I. Clearly, psychiatric/mental health clinical specialists face formidable challenges as the 21st century approaches. Are we slipping on banana peels, or can we gain sure footing and stride forward to the future
Sandra Thomas is professor and director of the PhD Program in Nursing at the University of Tennessee in Knoxville. This article is based on a presentation made at the 20th Annual Southeastern Conference of Clinical Specialists in Psychiatric-Mental Health Nursing, Nashville, TN, September 1998. Reprint requests: Sandra Thomas, RN, PhD, FAAN, College of Nursing, University of Tennessse, Knoxville, 1200 Volunteer Blvd, Knoxville, TN 3 7996-4180. J Am Psychiatr Nurses Assoc (1999). 5, 88-96. Copyright © 1999 by the American Psychiatric Nurses Association. 1078-3903/99/$8.00 + 0
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with confidence? Can we become empowered nurses w h o "run with the wolves," as Rafael (1998) has exhorted us to do? In sharp contrast to the optimistic mindset that prevailed from the 1950s to the 1970s (Aiken, 1987), pessimistic assessments of our specialty abound in the 1990s. As mental health services advance into primary care settings, psychiatric clinical specialists do not seem to be in step. In a report released b y the American Nurses Association (ANA) on June 1, 1998, an expert panel deplored the under-utilization of advanced practice psychiatric nurses (APPNs) in managed care and primary care service delivery systems, identifying a host of major barriers (ANA, 1998). Neither employers nor consumers are well informed about APPN knowledge and skills. State nurse practice acts are inconsistent, and prescriptive authority cannot be transferred from state to state. Legislation often mandates physician
As mental health services advance into primary care settings, psychiatric clinical specialists do not seem to be in step. supervision of APPN practice. Payment for services remains an issue, despite the 1997 achievement of Medicare reimbursement. No consensus exists on the preparation and role of the APPN. In fact, it is of grave concern to many in the field that separate certification examinations have b e e n p r o p o s e d for psychiatric/ mental health nurse practitioners (NPs) and clinical nurse specialists (CNSs), splitting the advanced practice role and potentially causing divisiveness among APPNs. After reviewing survey data from 675 certified psychiatric clinical specialists (Society for Education and Research in Psychiatric-Mental Health Nursing, 1997), Krauss characterized APPNs as "an aging, geographically diverse, maldistributed bunch w h o have not developed comprehensive or universal outcome measures which could be used to document our costVol. 5, No. 3
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effectiveness in a managed care environment, or any other environment for that matter" (p. 165). Krauss went on to decry declining enrollments in APPN programs, w o n d e r i n g w h o will replace our "aging bunch." Certainly, a specialty that is in confusion is not very attractive to potential students. Applicants to graduate programs are confused and disheartened as they see hospital-based CNSs moving away from direct patient services to administration (Smoyak & Skiba-King, 1998). Some of them believe they should obtain NP preparation to be marketable but find the physical tasks less appealing than the CNS role of psychotherapist. Some applicants seek a program that incorporates both clinical specialist and primary care competencies ("blended preparation"). However, some leaders in the field, such as Lego (1998), deplore this blending: "Combining the NP and the CNS is a further example of what some consider an anti-intellec-
Neither employers nor consumers are well informed about APPN knowledge and skills. tual, self-destructive streak in nursing. By watering down our specialty, following market forces to include primary care, we reduce our professional standing" (p. 5). What can we anticipate for the future? Is the prognosis grim? Is a watered-down psychiatric nursing specialty heading for a watery grave? In this Point of View article, I will explore the impact on the specialty of radical changes in the mental health care delivery system, encroachment by other professions, and serious societal issues confronting practitioners. I will ponder the question of the specialty's extinction, which is not a n e w one for me. A d o z e n years ago, along with a colleague, I wrote a paper entitled "Mental Health Nursing Clinical Specialization: Extinction or Adaptation?" (Thomas & Wilt, 1986). In 1986, we worried about unclear identity, paucity of research, decreased graduate enrollment, lack of cohesion, economic factors, exodus of practitioners to private practice, and separatism from our o w n nursing colleagues. We described mental health clinical specialists as "treading water and growing weary" (p. 4) but concluded with a call to "sculpt a dynamic adaptation" (p. 11). We recommended revision of graduate curricula to include more emphasis rune 1999
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on community assessment and preventive mental health. We exhorted colleagues to design innovative new systems of care, develop more sophisticated marketing and political skills, and join together in one powerful professional organization. We h o p e d that psychiatric nurses might achieve Slavinsky's (1984) optimistic prediction of arriving at the year 2000 in charge of the mental health system.
RADICAL CHANGES IN THE MENTAL HEALTH CARE DELIVERY SYSTEM Now the year 2000 is almost here. Most of our 1986 recommendations have not been implemented, nor has Slavinsky's (1984) prediction come true. We are not in charge of the mental health system. We are not even equal members of interdisciplinary teams (ANA, 1998). Sometimes we are virtually invisible among those various providers w h o are labeled "nonphysicians." In addition, the mental health system is a mess. The socalled "seamless system" of care delivery has come unraveled. Referring to the changes of the past 5 to 10 years as "radical" is almost an understatement. Managed care, of course, is the primary payer model. Most American workers (74%) are enrolled in managed care plans, whereas only 55% were enrolled in such plans in 1992 (Anderson, 1997). Driven by the exigencies of managed care, the health care system is changing so rapidly that none of us can keep track of all the hospital mergers and acquisitions, which equaled $134 billion in just 4 years (Institute for Health and Socio-Economic Policy, 1996). In fact, every 3 days another hospital merger or acquisition occurs (Cahill, 1997). Even though many of us do not work in hospitals, we have all felt the impact of capitation, competition, and closing of hospital beds and
Sometimes we are virtually invisible among those various providers who are labeled "nonphysicians." units. We have mastered a whole vocabulary of new words beginning with "re-": re-engineering, restructuring, redesigning. We have reeled u n d e r registered nurse layoffs and job losses in this once-secure profession (Thomas, 1998b). We have become discouraged at the increased frequency of our clients' relapse, imprisonment, and homelessness, as managed care APNA webs#e: w w w . a p n a . o r g 89
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allows them only brief therapies and "stabilization stays" of 5 or less days (E1-Sayad, 1998). We have deplored the new selectivity of inpatient units that refuse to accept patients who are dually diagnosed, aggressive, or "unable to participate in programs." We have struggled to meet the needs of the seriously mentally ill who have returned to the community after facilities and programs have closed.
ENCROACHMENT OF OTHER PROFESSIONS While psychiatric nurses have fought to keep their foothold on increasingly shaky ground, members of other professions have been marching into the territory. Psychiatric clinical nurse specialists responding to the 1997 Society for Education and Research in Psychiatric/ Mental Health Nursing (SERPN) survey specifically mentioned "encroachment by licensed clinical social workers." With the advent of managed care systems, social workers are often selected for positions formerly held by nurses; social workers are less expensive for profit-driven employers than are master's-prepared nurses. Social workers' lack of prescriptive authority seems to be their only disadvantage when employers compare them with nurses. Prescriptive privileges for psychotropic medications have become a hotly sought commodity, and mental health nurses who presently prescribe may soon lose their traditional advantage. Other professionals have been aggressive in seeking legislation permitting them to prescribe. Psychologists have instituted a vigorous training program in psychopharmacology, offered in cooperation with their state psychological associations, and the Prescribing Psychologists' Register now has 11,000 members (The Prescriber, n.d.)2 The American Psychological Association has authorized development of a national examination in psychopharmacology suitable for use by state licensing boards once their legislatures have granted prescriptive authority to psychologists. Legislation to grant such authority is either pending or soon to be introduced in California, Florida, Georgia, Hawaii, Louisiana, Missouri, and Tennessee, with activity in five other states underway (Fox & Sammons, 1998). To achieve prescriptive authority, some psychologists are going back to school to obtain a master's degree in nursing in "executive track" programs that require an average of five semesters of didactic and clinical instruction. Nurse educators are apparently happy to accommodate them, unconcerned that their newfound 90 APNA website: www.apna.org
interest in the nursing profession was sparked mainly by the need to prescribe. Family therapists are also interested in the prescribing issue. A curriculum for a graduate course in psychopharmacology for family therapists has been outlined (Patterson & Magulac, 1994). Objectives for the course include tactics for finding a psychiatrist collaborator who will prescribe medication for the therapist's clients. Although I am not aware of any attempts by family therapists to seek independent prescriptive authority, it is conceivable that an initiative could be mounted once a sizeable cadre of family therapists have taken psychopharmacology courses. The uniqueness of the APPN could be further eroded when more and more professionals have access to the prescription pad in a competitive health care marketplace.
SERIOUS SOCIETAL ISSUES CONFRONTING PRACTITIONERS As the 1990s draw to a close, serious societal issues confront practitioners. Although the "Decade of the Brain" enlightened the public about mental illness, lessening its stigma for clients and their families, insurance coverage for mental illness is still abysmal. Only 2% of US citizens with health care coverage have adequate provision in their policies for mental conditions (Thomas, 1998a). As a result, even if they recognize that they need professional help, many persons with anxiety disorders, depression, and other treatable illnesses remain outside the mental health treatment system. Another group of patients, diagnosed with severe mental illness such as schizophrenia or other psychoses, may be marginally or tangentially connected to the mental health treatment system but not well monitored or supervised by a consistent case manager. Societal discrimination often renders these severely mentally ill patients idle, even when they are capable of working. As shown in a national study, one in three of these patients has been turned down for a job for which they were qualified (National Alliance for the Mentally Ill, cited in "Study Finds Discrimination Still Pervasive," 1998). Thus the treatment and rehabilitative efforts of clinicians are often aborted or undermined by contextual factors in the larger society. Preventive mental health interventions are sorely needed by millions of children. The number of children living in high-risk situations escalates annually. To wit: One quarter of American children live in poverty; at least 7 million live with an alcoholic Vol. 5, No. 3
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parent; 10% to 20% live with a mentally ill parent; more than 300,000 live in foster care; hundreds of thousands are homeless; and tens of thousands have b e e n o r p h a n e d by the h u m a n immunodeficiency virus/acquired immunodeficiency syndrome epidemic (Zelman, 1996). In addition, a million children are abused each year, producing a grievous wounding of psyche and soul that is wearily familiar to mental
The uniqueness of the APPN could be further eroded when more and more professionals have access to the prescription pad in a competitive health care marketplace. health nurses (Mason, 1993). It is logical to predict that the incidence of mental illness in the next generation will increase exponentially. Already we are seeing frightening increases in violent crime by juveniles, m a n y of w h o m were neglected, abused, or abandoned in early childhood. According to Justice Department statistics, between 1988 and 1992, a 68% increase occurred in the number of juveniles charged with murder, aggravated assault, robbery, and forcible rape, with aggravated assault up 80% (cited in Coleman, 1995). If the trend continues, violent crime by juveniles will double by the year 2010 (Mulvey, Arthur, & Reppucci, 1997). We are already seeing mass murders by children for the first time in our nation's history. Never has early intervention with children and adolescents been so crucial. Lastly, I remind you of the 3 to 4 million w o m e n w h o are physically battered by their partners each year (American Medical Association, cited in Woodtli & Breslin, 1997), the 1.2 million elders w h o are abused annually (American Academy of Nursing Expert Panel on Violence, 1993), and the eve>increasing number of victims of sexual assault, the nation's fastest growing crime (Dunn & Gilchrist, 1993). The victims of all of these egregious violent crimes surely need counseling services to enable them to recover from the trauma, and most will not get it.
Societal Inertia Given the staggering scope and ramifications of these grim facts, society's inertia is curious. The neglect of America's mentally ill and vulnerable children is June 1999
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morally repugnant. Funding for social programs is actually decreasing (Mulvey, Arthur, & Reppucci, 1997). Where is the vision and activism of the 1970s, w h e n community mental health centers proliferated and ambitious outreach programs were developed? Where is the energy to tackle the serious problems I have enumerated? Even the dances of the late 1990s seem to exemplify societal inertia in contrast to those popular 20 years ago. In the 1970s, the "hustle" was perhaps emblematic of a society in frenetic motion to address the needs of the disenfranchised. Today we do the "macarena," in which your feet stay in the very same spot while you do a little squirming around. Is the macarena a metaphor for contemporary American political life?
SURVIVAL SKILLS WHEN YOU ARE SURROUNDED BY BANANA PEELS It does seem that psychiatric nursing is surrounded by banana peels on all sides. How can nurses in the specialty gain sure footing? How can we surmount the constraints that practicing specialists have identified? How can we advocate for the unserved and underserved whose unmet needs may eventually mire them in hopelessness? I propose that five skills are crucial: management of negative emotionality, achievement of collegial unity, understanding the nature of transitions, revising career trajectories, and marketing ourselves.
Management of Negative Emotionality In response to the discouraging set of circumstances I have just outlined, nurses are angry, and they are hurting. Studies of nurses' anger by my research team graphically document their cynicism about health care reform, their anxiety about their o w n professional future, and their outrage at a profit-driven care delivery system that leaves suicidal clients on the streets and chronic schizophrenics u n d e r the bridges (Thomas, 1998b). Feelings of powerlessness were pervasive in the interview data. Nurses on inpatient units were angry about not being involved in redesign of their units, not having a place at the table when decisions were being made, and not having sufficient resources to do their jobs. Nurses in rural areas were overwhelmed by the needs of clients for w h o m there is no mental health center, no day care, and no support groups. Too often the nurses felt that no one was really listening to them. Some were clearly on the path to burnout. My study findings (Thomas, 1998b) have been c o r APNA website: www.apna.org 91
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roborated by Lutzen and Schreiber (1998), who conducted focus groups with psychiatric/mental health nurses in three Canadian hospitals, and by Mohr (1994, 1995, 1996; Mohr & Mahon, 1996), who interviewed nurses in several for-profit Texas psychiatric hospitals that have b e e n investigated for fraud and unethical behavior. These studies showed that many psychiatric nurses have been forced to practice in situations that were incongruent with their personal and professional values. Lutzen and Schreiber (1998) identified survival strategies that included administration bashing, scapegoating, and perpetuating the doctornurse game. Although frustrated and angry at "the system," nurses' anger was largely suppressed while on the job, as exemplified in this excerpt from a study by Mohr and Mahon (1996): ...I have just learned to put my frustrations in a box and put them aside and say, okay, n o w I've got to set up the 9:00 [medications]...I've got to take off the orders. You learn to stifle it, the rage. You learn to put aside your feelings and your expectations and your hopes and dreams and get on with the business at hand. (p. 34) The tragedy is that eventually this stifled anger may take its toll in substance use and physical health problems (Thomas, 1998b). Furthermore, Boey (1999) found that negative emotion-focused coping exacerbates nurses' work stress. The study s h o w e d that stress-resistant nurses, those with good mental health despite high stress, were less likely to use negative emotion-focused coping (e.g., suppression o f feelings, blaming others, becoming defensive). Instead, they engaged in direct behavioral coping with problems. Simoni and Paterson (1997) reported similar findings. They found that nurses using direct active coping with stressors (e.g., changing the stressor, confronting the stressor, finding positive aspects in the situation) had the lowest burnout scores. It is time for all nurses to turn their impotent festering anger into productive problem-solving action (Thomas, 1998b). Here is an example of psychiatric nurses transforming a workplace: As the nurses themselves described their situation, they were part of a "fiercely patriarchal and autocratic hospital culture" (Breda et al., 1997, p. 77). Fortunately, they understood that if changes were to occur, their own actions would have to be the catalyst, so a small group of nurses undertook a project to increase the autonomy of the 92 APNA website: www.apna.org
nurses there. The project involved a number of elements, including formation of a study group to prepare for certification, incorporation of new holistic healing interventions into their practice, presentation of educational sessions and retreats for the staff, and increased participation in multidisciplinary teams. From an oppressed group, the nurses evolved to b e c o m e increasingly confident, outspoken, and articulate: The...project allowed us to experience a new sense of dignity about ourselves as professionals, which we call "ownership of practice." Ownership of practice includes many of the dimensions of a u t o n o m y - - c o n t r o l over our practice, the freedom to make decisions, and the quality of professional exchange with colleagues that we always sought .... Above all, we developed a firm sense of making a difference with clients and within the organization as a whole. We had become secure in our knowledge base and were no longer willing to be subordinated by others. We recognized that autonomy is linked to power and that the many limits placed on our practice were simply a way to keep nurses in line. (Breda et al., 1997, p. 79) These nurses were experiencing a healthy sense of power. However, many nurses are not comfortable with seeking p o w e r - - a n o t h e r banana peel that can cause slippage at a time w h e n mobilizing their power is critical for APPNs. Power is essential to advocate for vulnerable clients and for our own usefulness in profit-driven managed care systems. However, power and caring have been viewed as antithetical by many nurses. Rafael (1996) p r o p o s e d a new view of CARE (Credentials, Association, Research, and Expertise) so that nurses can accomplish empowered caring. APPNs already have credentials (graduate degrees, certifications) 'that confer credibility. We also have considerable expertise, developed within the rich tradition of clinical scholarship initiated by our founding mother, Hildegard Peplau. However, we fall short in the areas of association and research. By association, Rafael means working with other nurses in professional organizations, as well as aligning with powerful political figures. Psychiatric nursing has p r o d u c e d some notable national leaders, including Peplau, the only individual ever to serve as both president and executive director of ANA; ANA past presidents Lucille Joel and Virginia Betts; and the current ANA president,
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Beverly Malone. However, not enough specialists in psychiatric/mental health nursing are actively involved in organizations, and the multiplicity of organizations competing for their dues dollars is a significant hindrance to unity.
Achievement of Collegial Unity Collegial unity is essential for addressing the challenges we face. It is an old truism that there is strength in numbers. We must present a coherent lobbying agenda for mental health nursing to policymakers and legislators. For example, we should be working together to seek
Power is essential to advocate for vulnerable clients and for our own usefulness in profit-driven managed care systems. Medicaid reimbursement. Currently, Medicaid reimburses only certified pediatric nurse practitioners, certified family nurse practitioners, and certified nurse midwives. Legislation has been introduced in both the House of Representatives (H.R. 1354) and the Senate (S. 1326) to provide Medicaid reimbursement to all NPs and CNSs. This legislation could enable APPNs to serve millions of unserved inner-city and rural residents who need mental health care. However, our specialty has no unified voice. I thought that it was an excellent idea to merge three psychiatric nursing organizations--SERPN, International Society of Psychiatric Consultation Liaison Nurses (ISPCLN), and Association of Child and Adolescent Psychiatric Nurses (ACAPN)--into one, subsequently n a m e d the International Society of Psychiatric-Mental Health Nurses (ISPN). This new organization was ratified by the boards and memberships of all three groups in June 1998. Unfortunately, the American Psychiatric Nurses Association remains separate from the International Society of PsychiatricMental Health Nurses. How many organizations make sense for one nursing specialty? O n c e again, there may be unnecessary splintering of the specialty's talents and energies, a banana peel of our own creation.
Understanding the Nature of Transitions The specialty of psychiatric nursing, like all of nursing, is in a time of transition. Transitions are always diffiJune i9 9 9
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cult and are more so when they occur suddenly and without choice. Psychiatric nurses thrust into the primary care world face an uncomfortable culture clash. For example, the lengthy assessment process of psychiatric specialists, with its careful attention to establishment of trust and rapport with clients, is devalued in a primary care culture that emphasizes speed in evaluation (Chafetz & Bride, 1998). However, we must learn to survive and thrive in this new world, because that is where our clients are. More than 70% of all patients with diagnosed mental health disorders are never seen by a mental health professional and are treated only in primary care (McDaniel et al., cited in Cotroneo, Outlaw, King, & Brince, 1998). We can never go back to the way things were. What can we glean from research about transitions? Levinson (1978, 1996) completed one of the best empirical examinations of life transitions. Through in-depth study of the lives of men and women, he learned that the life structure evolves through a sequence of alternating stable periods and transitional periods. Each of the transitional periods lasts about 5 years. Therefore, if you tally up these periods, almost half our adult lives is spent in transition (Levinson, 1996). I believe Levinson's research should give us a healthier perspective on disruptive change: it is inevitable, it is predictable, and it is surmountable. Most of us grow in c o m p e t e n c e and ego strength because of these periods of turmoil and questioning.
Revising Career Trajectories Many nurses are job-scared, especially those w h o have been watching colleagues in CNS positions get pink slips during hospital downsizing. Although hospital jobs are decreasing, future practice options and sites are proliferating. Psychiatric nurses must revise career trajectories and avail themselves of opportunities in school health, eldercare, and the workplace. Opportunities will soon abound in telemental health, which is expected to be a major component of psychological service delivery in the next millennium, improving access of isolated, and rural clients to therapy. I believe that a heyday for nurse entrepreneurs is coming. More and more nurses will be presidents of their own businesses, from hospices and adult day care establishments to holistic healing centers and consulting firms of all types (Thomas, 1998b). As Dreher (1996) points out, "It is essential to make the distinction between your job and your career....A job is not a career; rather, it is just the vehicle through APNA webs#e: www.apna.org 93
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which we express our career goals. If it no longer holds the possibility for doing that, it probably is time to look for or create a new vehicle" (p. 7). The word "create" in that last sentence is crucial. The mindset of the APPN of the 21st century must be one of innovation. Seizing opportunities to create new positions and roles will be crucial to the survival of psychiatric/mental health nursing.
Marketing Ourselves Clearly, many employers are not aware of what the APPN can offer with regard to screening, assessment, therapeutic management, case management, and prescriptive privileges (ANA, 1998). They may not know that the holistic philosophy of nurses mandates that we are more than "Prozac dispensers" (Jones, 1998), committed to thoughtfully considering our clients' bodies, minds, and spirits as well as the environmental contexts in which they struggle to live and work. Employers may not k n o w that psychiatric/mental health nurses are adept in family, group, and community interventions, unlike many other providers whose expertise is mainly in provision of individual psychotherapy. Strengths that psychiatric nurses bring to the primary care arena include their biopsychosocial orientation, ability to collaborate across professions, experience as client educators and advocates, and history of independent practice (Cotroneo et al., 1998). How will employers learn about our qualifications and capabilities unless we tell them? Perhaps because of archaic admonitions regarding feminine modesty, the predominantly female nursing profession has b e e n slow to incorporate effective self-marketing principles. We can no longer afford misguided reticence about what we know and do. Research makes visible what nurses do (Rafael, 1996). Clearly, the foremost mandate for psychiatric/mental health nursing research is documentation of effective interventions with regard to client symptom reduction, improved function and quality of life, and decreased family burden. The nursing interventions that are "core" to each clinical specialty (i.e., central to defining the nature of the specialty) have already been identified by the Nursing Interventions Classification project at the University of Iowa (McCloskey, Bulechek, & Donahue, 1998). More than 40 interventions are commonly performed by special L ists in psychiatric/mental health nursing. Hallucination management, eating disorders management, cognitive restructuring, c o m p l e x relationship building, and 94 APNA website: www.apna.org
impulse control training are illustrative items from the Nursing Interventions Classification list. Many research questions have yet to be answered about these interventions. When should the intervention be used? When is it contraindicated? Should it be delivered in conjunction with other nursing and/or medical interventions? Should it be delivered antecedent to, along with, or following psychotropic medication? Must it be delivered to individuals, or could it be successfully used with families and groups? What does it cost? What specific outcomes can be predicted, and h o w can they be measured? What is the "nurse dose" needed to show an effect on patient outcomes? It is disturbing that one third of the respondents to the SERPN survey did not use any outcome measures to evaluate
Psychiatric nurses must revise career trajectories and avail themselves of opportunities M school health, eldercare, and the workplace. the effectiveness of their interventions (Barrell, Merwin, & Poster, 1997). If our best-educated practitioners (90.3% of the specialists were master's prepared and 8% were doctorally prepared) have no data to d o c u m e n t the quality and effectiveness of their care, what data can we show to legislators and policymakers to support removal of the constraints to advanced practice? Practicing nurses' priorities were identified in a Delphi survey conducted by Davidson, Merritt-Gray, Buchanan, and Noel (1997), who developed an excellent list of research questions. Their list included: What approaches are most effective for patients w h o frequently use the system with minimal outcome? How is client outcome affected by the availability of a 24-hour crisis service? H o w have budget cutbacks affected the quality and level of client care? What factors influence the burnout of mental health nurses after 5 to 10 years of practice? McBride (1996) asserts that psychiatric nursing research should be particularly concerned with h o w to care for the persistently mentally ill. She points out that even if a cure for schizophrenia appears tomorrow, millions of people will n e e d rehabilitation. In addition, they will still n e e d support from caregivers as they negotiate the challenges of living that reVol. 5, No. 3
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main after the disease process is reversed. Psychiatric nurses care about these patients with a passion unmatched by any other group of providers. Where is the research to d o c u m e n t our effectiveness with this client population? Finding the answers to questions such as these can keep us busy well into the 21st century.
CONCLUSION Futurists are bombarding us with their prognostications as the new millennium approaches. Columbia University's Eli Ginsberg asserts that m a n a g e d care cannot sustain its current growth and industry domi-
It is incumbent upon mental health nurses to demonstrate our unique expertise and value as the dizzying changes in the health care system continue. nance. Furthermore, it will be unable to answer the needs of the American people for universal coverage, sustainable financing, and better care (Ginzberg, 1997). Public concern has grown into a strong backlash against the profit-oriented practices of managed care plans. Consequently, legislation aimed at regulating managed care to protect patients has been introd u c e d in nearly every state. On the federal level, efforts continue to achieve passage of the Patient Safety Act that was first introduced in 1996. Concerns of professionals about ethical dilemmas in managed care settings led to the August 1998 release of an important d o c u m e n t by the National Academies of Practice (which includes the academies of medicine, nursing, psychology, and seven other professions). This document, "Ethical Guidelines for Professional Care and Services in a Managed Health Care Environment," asserts in part, "It is the position of the National Academies of Practice that it is unethical to compromise a patient's needs and quality care concerns to satisfy financial objectives. The patient's right to appropriate care must not be diluted by economic pressures" ("Ethical Guidelines," 1998, p. 2). Ironically, Ginzberg has exposed the fallacy that managed care is cutting costs. During the years of managed care's rapid ascendance, health care costs have not decreased but June I999
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rather quadrupled (from $250 billion in 1980 to $1 trillion in 1995). Hence, convulsive restructuring and reconfiguring of the health care delivery system will continue. Merger mania is n o w evident in the managed care area, with large managed care organizations (MCOs) acquiring smaller MCOs and the larger MCOs merging. Integrated delivery systems are sweeping the United States along with this merger mania. Mental health nurses must be proactive in developing strategies for adaptation to these trends. Spiraling costs must be contained, but patients' rights must not be abrogated in the process. Many experts envision a bright future for nursing. For example, Buerhaus predicts that the value of nurses will rise over the next 10 years (Buerhaus, cited in Nursing Leadership in the 21st Century, 1996). Wykle foresees the nurse of the future as the "hub in the wheel" as manager and coordinator of all providers instrumental in promoting the health of the population (Wykle, cited in Nursing Leadership for the 21st Century, 1996). It is incumbent u p o n mental health nurses to demonstrate our unique expertise and value as the dizzying changes in the health care system continue. When psychiatric nurses stride forward to the n e w millennium with confident proactive steps, no banana peels can cause them to slip.
REFERENCES American Academy of Nursing (AAN) Expert Panel on Violence. (1993). AAN working paper: Violence as a nursing priority: Policy implications. Nursing Outlook, 41, 83-92. Aiken, L. H. (1987). Unmet needs of the chronicallymentally ill: Will nursing respond? IMAGE..Journal of Nursing Scholarship, 19, 121-125. American Nurses Association. (1998). A review of and recommendationsfor standards and guidelinesfor the delivery of substance abuse and mental health services, curricula, and training modelsfor working in managed care and otherprimary care settings.
Washington, DC: Author. Anderson, C. A. (1997). What is happening?Nursing Outlook, 45, 5-6. Barretl, L. M., Merwin, E. I., & Poster, E. C. (1997). Patient outcomes used by advanced practice psychiatric nurses to evaluate effectiveness of practice. Archives of Psychiatric Nursing, 11, 184-197. Boey, K. W. (1999). Distressed and stress resistant nurses. Issues in Mental Health Nursing, 20, 33-54. Breda, K. L., Anderson, M. A., Hansen, L., Hayes, D., Pillion, C., & Lyon, P. (1997). Enhanced nursing autonomy through participatory action research. Nursing Outlook, 45, 76-81. Cahill, S. (1997, March 3). The Wal-Martof hospitals. In These Times, pp. 14-16. Chafetz, L., & Bride, G. C. (1998). The case for comprehensive role preparation. In A.W. Burgess (Ed.), Advanced practice psychiatric nursing (pp. 6-13). Stamford, CT: Appleton & Lange. Cotroneo, M., Outlaw, F. H., King, J. K., & Brince, J. (1998). Advancing psychiatricnursing in a reforming health care system. APNA website: w w w . a p n a . o r g 95
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In A.W. Burgess (Ed.), Advanced practice psychiatric nursing (pp. 27-39). Stamford, CT: Appleton & Lange. Davidson, P., Merritt-Gray, M., Buchanan, J., & Noel, J. (1997). Voices from practice: Mental health nurses identify research priorities. Archives of Psychiatric Nursing, 11, 340-345. Dreher, M. (1996). Clinical scholarship: The key to survival in an era of managed care. Paper presented at the 1996-1997 Regional Assemblies of Sigma Theta Tau International. Dunn, S. E M., & Gilchrist, V. J. (1993). Sexual assault. Primary Care, 20, 359-373. El-Sayad, L. (1998). Families need support during chronic mental illness. Tennessee Nurse, 61(4), 13-14. Ethical guidelines for professional care and services in a managed health care environment. (1998). Edgewood, MD: National Academies of Practice. Fox, R. E., & Sammons, M. T. (1998). A history of prescription privileges. American Psychological Association Monitor, 29(9), 42-43. Ginzberg, E. (1997). Managed care and the competitive market in health care: What they can and cannot do. Journal of the American Medical Association, 277, 1812-1813. Goleman, D. (1995). Emotional intelligence. New York: Bantam. Institute for Health and Socio-Economic Policy. (1996). Wealth and power: The U.S. health care industry. Revolution: The Journal of Nurse Empowerment, 6(4), 67-70. Jones, S. L. (1998). Do we have a choice? Archives of Psychiatric Nursing, 12, 179-180. Krauss, J. B. (1997). The future of advanced practice psychiatric nursing. Archives of Psychiatric Nursing, 11, 165-166. Lego, S. (1998). The case against merging the CNS and NP roles. In A.W. Burgess (Ed.), Advanced practice psychiatric nursing (pp. 1-5). Stamford, CT: Appleton & Lange. Levinson, D.J. (1978). The seasons of a man's life. New York: Knopf. Levinson, D. J. (1996). The seasons of a woman's life. New York: Ballantine. Lutzen, K., & Schreiber, R. (1998). Moral survival in a nontherapeutic environment. Issues in Mental Health Nursing, I9, 303-315. Mason, J. O. (1993). The dimensions of an epidemic of violence. Public Health Reports, 108(1), 1-3. McBride, A. B. (1996) Psychiatric-mental health nursing in the twenty-first century. In A.B. McBride and J. K. Austin (Eds.), Psychiatric-mental health nursing: Integrating the behavioral and biological sciences (pp. 1-10). Philadelphia: Saunders. McCloskey, J. C., Bulechek, G. M., & Donahue, W. (1998). Nursing interventions core to specialty practice. Nursing Outlook, 46, 67-76. Mohr, W. (1994). The private psychiatric hospital scandal: A critical social approach. Archives of Psychiatric Nursing, 8, 4-8. Mohr, W. (1995). Multiple ideologies and their proposed roles in the outcomes of nurse practice setting: The for-profit psychiatric hospital scandal as a paradigm case. Nursing Outlook, 43, 35-43.
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Mohr, W. (1996). Psychiatric nursing in troubled environmental contexts. Archives of Psychiatric Nursing, IO, 197-206. Mohr, W., & Mahon, M.M. (1996). Dirty hands: The underside of marketplace health care. Advances in Nursing Science, 19(1), 28-37. . Mulvey, E. P., Arthur, M. W., & Reppucci, N. D. (1997). The prevention of juvenile delinquency: A review of the research. The Prevention Researcher, 4(2), 1-4. Nursing leadership in the 2I st century: A report of ARISTA II (1996). Indianapolis: Center Nursing Press, Sigma Theta Tau International. Patterson, J. E., & Magulac, M. (1994). The family therapist's guide to psychopharmacology: A graduate level course. Journal of Marital and Family Therapy, 20, 151-173. Rafael, A. R. (1996). Power and caring: A dialectic in nursing. Advances in Nursing Science, 19(1), 3-17. Rafael, A. R. (1998). Nurses who run with the wolves: The power and caring dialectic revisited. Advances in Nursing Science, 21(1), 29-42. Society for Education and Research in Psychiatric-Mental Health Nursing. (1997). Primary mental health and advanced practice psychiatric nursing. Pensacola, FL: Author. Simoni, P. S., & Paterson, J. J. (1997). Hardiness, coping, and burnout in the nursing workplace. Journal of Professional Nursing, 13, 178-185. Slavinsky, A. (1984). Psychiatric nursing in the year 2000: From a nonsystem of care to a caring system. Image, I6, 17-20. Smoyak, S., & Skiba-King, E. W. (1998). Historical influences on today's education and practice. In A. W. Burgess (Ed.), Advanced practice psychiatric nursing (pp. 15-26). Stamford, CT: Appleton & Lange. Study finds discrimination still pervasive. (1998). Update of the Tennessee Department of Mental Health and Mental Retardation, 4 (1), 3. The Prescriber. (n.d.). North Miami Beach, FL: Prescribing Psychologists' Register. Thomas, S. P. (1998a). Mental health nursing interventions for the generalist nurse [Preface to special issue]. Nursing Clinics of North America, 33, 119-120. Thomas, S. R (1998b). Transforming nurses' anger and pain: Steps toward healing. New York: Springer Publishing. Thomas, S. P., & Wilt, D. (1986). Mental health nursing clinical specialization: Extinction or adaptation? Issues in Mental Health Nursing, 8, 1-13. Woodtli, M. A., & Breslin, E. T. (1997). Violence and the nursing curriculum: Nurse educators speak out. Nursing and Health Care Perspectives, I8, 252-259. Zelman, A. B. (1996). Early intervention with high-risk children: Freeing prisoners of circumstance. New York: Jason Aronson.
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Point o f View Surrounded by Banana Peels: Is Psychiatric Nursing Slipping?. Sandra Thomas, RN, PhD, FAAN
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a caseload of 2000 patients. I see 50 to per day in medication clinic. They get no teaching, no therapy." "I need a physician to sign off on my prescriptions every 3 months. One doctor I approached about doing this wanted 50% of my salary to do it." "Family nurse practitioners are flooding the market. They don't know an antipsychotic from an antidepressant, but they are allowed full prescription privileges." "Psych specialists are a dying breed. I look with nostalgia at my practice in the 1980s." These are the voices of psychiatric clinical specialists venting their anger and discouragement in the turbulent, waning years of the 20th century. Some are longing for the past rather than gearing up for the future. They are remembering the once-proud specialty that pioneered national certification and development of standards for specialty practice. They are worried, and so am I. Clearly, psychiatric/mental health clinical specialists face formidable challenges as the 21st century approaches. Are we slipping on banana peels, or can we gain sure footing and stride forward to the future
Sandra Thomas is professor and director of the PhD Program in Nursing at the University of Tennessee in Knoxville. This article is based on a presentation made at the 20th Annual Southeastern Conference of Clinical Specialists in Psychiatric-Mental Health Nursing, Nashville, TN, September 1998. Reprint requests: Sandra Thomas, RN, PhD, FAAN, College of Nursing, University of Tennessse, Knoxville, 1200 Volunteer Blvd, Knoxville, TN 3 7996-4180. J Am Psychiatr Nurses Assoc (1999). 5, 88-96. Copyright © 1999 by the American Psychiatric Nurses Association. 1078-3903/99/$8.00 + 0
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with confidence? Can we become empowered nurses w h o "run with the wolves," as Rafael (1998) has exhorted us to do? In sharp contrast to the optimistic mindset that prevailed from the 1950s to the 1970s (Aiken, 1987), pessimistic assessments of our specialty abound in the 1990s. As mental health services advance into primary care settings, psychiatric clinical specialists do not seem to be in step. In a report released b y the American Nurses Association (ANA) on June 1, 1998, an expert panel deplored the under-utilization of advanced practice psychiatric nurses (APPNs) in managed care and primary care service delivery systems, identifying a host of major barriers (ANA, 1998). Neither employers nor consumers are well informed about APPN knowledge and skills. State nurse practice acts are inconsistent, and prescriptive authority cannot be transferred from state to state. Legislation often mandates physician
As mental health services advance into primary care settings, psychiatric clinical specialists do not seem to be in step. supervision of APPN practice. Payment for services remains an issue, despite the 1997 achievement of Medicare reimbursement. No consensus exists on the preparation and role of the APPN. In fact, it is of grave concern to many in the field that separate certification examinations have b e e n p r o p o s e d for psychiatric/ mental health nurse practitioners (NPs) and clinical nurse specialists (CNSs), splitting the advanced practice role and potentially causing divisiveness among APPNs. After reviewing survey data from 675 certified psychiatric clinical specialists (Society for Education and Research in Psychiatric-Mental Health Nursing, 1997), Krauss characterized APPNs as "an aging, geographically diverse, maldistributed bunch w h o have not developed comprehensive or universal outcome measures which could be used to document our costVol. 5, No. 3
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effectiveness in a managed care environment, or any other environment for that matter" (p. 165). Krauss went on to decry declining enrollments in APPN programs, w o n d e r i n g w h o will replace our "aging bunch." Certainly, a specialty that is in confusion is not very attractive to potential students. Applicants to graduate programs are confused and disheartened as they see hospital-based CNSs moving away from direct patient services to administration (Smoyak & Skiba-King, 1998). Some of them believe they should obtain NP preparation to be marketable but find the physical tasks less appealing than the CNS role of psychotherapist. Some applicants seek a program that incorporates both clinical specialist and primary care competencies ("blended preparation"). However, some leaders in the field, such as Lego (1998), deplore this blending: "Combining the NP and the CNS is a further example of what some consider an anti-intellec-
Neither employers nor consumers are well informed about APPN knowledge and skills. tual, self-destructive streak in nursing. By watering down our specialty, following market forces to include primary care, we reduce our professional standing" (p. 5). What can we anticipate for the future? Is the prognosis grim? Is a watered-down psychiatric nursing specialty heading for a watery grave? In this Point of View article, I will explore the impact on the specialty of radical changes in the mental health care delivery system, encroachment by other professions, and serious societal issues confronting practitioners. I will ponder the question of the specialty's extinction, which is not a n e w one for me. A d o z e n years ago, along with a colleague, I wrote a paper entitled "Mental Health Nursing Clinical Specialization: Extinction or Adaptation?" (Thomas & Wilt, 1986). In 1986, we worried about unclear identity, paucity of research, decreased graduate enrollment, lack of cohesion, economic factors, exodus of practitioners to private practice, and separatism from our o w n nursing colleagues. We described mental health clinical specialists as "treading water and growing weary" (p. 4) but concluded with a call to "sculpt a dynamic adaptation" (p. 11). We recommended revision of graduate curricula to include more emphasis rune 1999
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on community assessment and preventive mental health. We exhorted colleagues to design innovative new systems of care, develop more sophisticated marketing and political skills, and join together in one powerful professional organization. We h o p e d that psychiatric nurses might achieve Slavinsky's (1984) optimistic prediction of arriving at the year 2000 in charge of the mental health system.
RADICAL CHANGES IN THE MENTAL HEALTH CARE DELIVERY SYSTEM Now the year 2000 is almost here. Most of our 1986 recommendations have not been implemented, nor has Slavinsky's (1984) prediction come true. We are not in charge of the mental health system. We are not even equal members of interdisciplinary teams (ANA, 1998). Sometimes we are virtually invisible among those various providers w h o are labeled "nonphysicians." In addition, the mental health system is a mess. The socalled "seamless system" of care delivery has come unraveled. Referring to the changes of the past 5 to 10 years as "radical" is almost an understatement. Managed care, of course, is the primary payer model. Most American workers (74%) are enrolled in managed care plans, whereas only 55% were enrolled in such plans in 1992 (Anderson, 1997). Driven by the exigencies of managed care, the health care system is changing so rapidly that none of us can keep track of all the hospital mergers and acquisitions, which equaled $134 billion in just 4 years (Institute for Health and Socio-Economic Policy, 1996). In fact, every 3 days another hospital merger or acquisition occurs (Cahill, 1997). Even though many of us do not work in hospitals, we have all felt the impact of capitation, competition, and closing of hospital beds and
Sometimes we are virtually invisible among those various providers who are labeled "nonphysicians." units. We have mastered a whole vocabulary of new words beginning with "re-": re-engineering, restructuring, redesigning. We have reeled u n d e r registered nurse layoffs and job losses in this once-secure profession (Thomas, 1998b). We have become discouraged at the increased frequency of our clients' relapse, imprisonment, and homelessness, as managed care APNA webs#e: w w w . a p n a . o r g 89
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allows them only brief therapies and "stabilization stays" of 5 or less days (E1-Sayad, 1998). We have deplored the new selectivity of inpatient units that refuse to accept patients who are dually diagnosed, aggressive, or "unable to participate in programs." We have struggled to meet the needs of the seriously mentally ill who have returned to the community after facilities and programs have closed.
ENCROACHMENT OF OTHER PROFESSIONS While psychiatric nurses have fought to keep their foothold on increasingly shaky ground, members of other professions have been marching into the territory. Psychiatric clinical nurse specialists responding to the 1997 Society for Education and Research in Psychiatric/ Mental Health Nursing (SERPN) survey specifically mentioned "encroachment by licensed clinical social workers." With the advent of managed care systems, social workers are often selected for positions formerly held by nurses; social workers are less expensive for profit-driven employers than are master's-prepared nurses. Social workers' lack of prescriptive authority seems to be their only disadvantage when employers compare them with nurses. Prescriptive privileges for psychotropic medications have become a hotly sought commodity, and mental health nurses who presently prescribe may soon lose their traditional advantage. Other professionals have been aggressive in seeking legislation permitting them to prescribe. Psychologists have instituted a vigorous training program in psychopharmacology, offered in cooperation with their state psychological associations, and the Prescribing Psychologists' Register now has 11,000 members (The Prescriber, n.d.)2 The American Psychological Association has authorized development of a national examination in psychopharmacology suitable for use by state licensing boards once their legislatures have granted prescriptive authority to psychologists. Legislation to grant such authority is either pending or soon to be introduced in California, Florida, Georgia, Hawaii, Louisiana, Missouri, and Tennessee, with activity in five other states underway (Fox & Sammons, 1998). To achieve prescriptive authority, some psychologists are going back to school to obtain a master's degree in nursing in "executive track" programs that require an average of five semesters of didactic and clinical instruction. Nurse educators are apparently happy to accommodate them, unconcerned that their newfound 90 APNA website: www.apna.org
interest in the nursing profession was sparked mainly by the need to prescribe. Family therapists are also interested in the prescribing issue. A curriculum for a graduate course in psychopharmacology for family therapists has been outlined (Patterson & Magulac, 1994). Objectives for the course include tactics for finding a psychiatrist collaborator who will prescribe medication for the therapist's clients. Although I am not aware of any attempts by family therapists to seek independent prescriptive authority, it is conceivable that an initiative could be mounted once a sizeable cadre of family therapists have taken psychopharmacology courses. The uniqueness of the APPN could be further eroded when more and more professionals have access to the prescription pad in a competitive health care marketplace.
SERIOUS SOCIETAL ISSUES CONFRONTING PRACTITIONERS As the 1990s draw to a close, serious societal issues confront practitioners. Although the "Decade of the Brain" enlightened the public about mental illness, lessening its stigma for clients and their families, insurance coverage for mental illness is still abysmal. Only 2% of US citizens with health care coverage have adequate provision in their policies for mental conditions (Thomas, 1998a). As a result, even if they recognize that they need professional help, many persons with anxiety disorders, depression, and other treatable illnesses remain outside the mental health treatment system. Another group of patients, diagnosed with severe mental illness such as schizophrenia or other psychoses, may be marginally or tangentially connected to the mental health treatment system but not well monitored or supervised by a consistent case manager. Societal discrimination often renders these severely mentally ill patients idle, even when they are capable of working. As shown in a national study, one in three of these patients has been turned down for a job for which they were qualified (National Alliance for the Mentally Ill, cited in "Study Finds Discrimination Still Pervasive," 1998). Thus the treatment and rehabilitative efforts of clinicians are often aborted or undermined by contextual factors in the larger society. Preventive mental health interventions are sorely needed by millions of children. The number of children living in high-risk situations escalates annually. To wit: One quarter of American children live in poverty; at least 7 million live with an alcoholic Vol. 5, No. 3
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parent; 10% to 20% live with a mentally ill parent; more than 300,000 live in foster care; hundreds of thousands are homeless; and tens of thousands have b e e n o r p h a n e d by the h u m a n immunodeficiency virus/acquired immunodeficiency syndrome epidemic (Zelman, 1996). In addition, a million children are abused each year, producing a grievous wounding of psyche and soul that is wearily familiar to mental
The uniqueness of the APPN could be further eroded when more and more professionals have access to the prescription pad in a competitive health care marketplace. health nurses (Mason, 1993). It is logical to predict that the incidence of mental illness in the next generation will increase exponentially. Already we are seeing frightening increases in violent crime by juveniles, m a n y of w h o m were neglected, abused, or abandoned in early childhood. According to Justice Department statistics, between 1988 and 1992, a 68% increase occurred in the number of juveniles charged with murder, aggravated assault, robbery, and forcible rape, with aggravated assault up 80% (cited in Coleman, 1995). If the trend continues, violent crime by juveniles will double by the year 2010 (Mulvey, Arthur, & Reppucci, 1997). We are already seeing mass murders by children for the first time in our nation's history. Never has early intervention with children and adolescents been so crucial. Lastly, I remind you of the 3 to 4 million w o m e n w h o are physically battered by their partners each year (American Medical Association, cited in Woodtli & Breslin, 1997), the 1.2 million elders w h o are abused annually (American Academy of Nursing Expert Panel on Violence, 1993), and the eve>increasing number of victims of sexual assault, the nation's fastest growing crime (Dunn & Gilchrist, 1993). The victims of all of these egregious violent crimes surely need counseling services to enable them to recover from the trauma, and most will not get it.
Societal Inertia Given the staggering scope and ramifications of these grim facts, society's inertia is curious. The neglect of America's mentally ill and vulnerable children is June 1999
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morally repugnant. Funding for social programs is actually decreasing (Mulvey, Arthur, & Reppucci, 1997). Where is the vision and activism of the 1970s, w h e n community mental health centers proliferated and ambitious outreach programs were developed? Where is the energy to tackle the serious problems I have enumerated? Even the dances of the late 1990s seem to exemplify societal inertia in contrast to those popular 20 years ago. In the 1970s, the "hustle" was perhaps emblematic of a society in frenetic motion to address the needs of the disenfranchised. Today we do the "macarena," in which your feet stay in the very same spot while you do a little squirming around. Is the macarena a metaphor for contemporary American political life?
SURVIVAL SKILLS WHEN YOU ARE SURROUNDED BY BANANA PEELS It does seem that psychiatric nursing is surrounded by banana peels on all sides. How can nurses in the specialty gain sure footing? How can we surmount the constraints that practicing specialists have identified? How can we advocate for the unserved and underserved whose unmet needs may eventually mire them in hopelessness? I propose that five skills are crucial: management of negative emotionality, achievement of collegial unity, understanding the nature of transitions, revising career trajectories, and marketing ourselves.
Management of Negative Emotionality In response to the discouraging set of circumstances I have just outlined, nurses are angry, and they are hurting. Studies of nurses' anger by my research team graphically document their cynicism about health care reform, their anxiety about their o w n professional future, and their outrage at a profit-driven care delivery system that leaves suicidal clients on the streets and chronic schizophrenics u n d e r the bridges (Thomas, 1998b). Feelings of powerlessness were pervasive in the interview data. Nurses on inpatient units were angry about not being involved in redesign of their units, not having a place at the table when decisions were being made, and not having sufficient resources to do their jobs. Nurses in rural areas were overwhelmed by the needs of clients for w h o m there is no mental health center, no day care, and no support groups. Too often the nurses felt that no one was really listening to them. Some were clearly on the path to burnout. My study findings (Thomas, 1998b) have been c o r APNA website: www.apna.org 91
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roborated by Lutzen and Schreiber (1998), who conducted focus groups with psychiatric/mental health nurses in three Canadian hospitals, and by Mohr (1994, 1995, 1996; Mohr & Mahon, 1996), who interviewed nurses in several for-profit Texas psychiatric hospitals that have b e e n investigated for fraud and unethical behavior. These studies showed that many psychiatric nurses have been forced to practice in situations that were incongruent with their personal and professional values. Lutzen and Schreiber (1998) identified survival strategies that included administration bashing, scapegoating, and perpetuating the doctornurse game. Although frustrated and angry at "the system," nurses' anger was largely suppressed while on the job, as exemplified in this excerpt from a study by Mohr and Mahon (1996): ...I have just learned to put my frustrations in a box and put them aside and say, okay, n o w I've got to set up the 9:00 [medications]...I've got to take off the orders. You learn to stifle it, the rage. You learn to put aside your feelings and your expectations and your hopes and dreams and get on with the business at hand. (p. 34) The tragedy is that eventually this stifled anger may take its toll in substance use and physical health problems (Thomas, 1998b). Furthermore, Boey (1999) found that negative emotion-focused coping exacerbates nurses' work stress. The study s h o w e d that stress-resistant nurses, those with good mental health despite high stress, were less likely to use negative emotion-focused coping (e.g., suppression o f feelings, blaming others, becoming defensive). Instead, they engaged in direct behavioral coping with problems. Simoni and Paterson (1997) reported similar findings. They found that nurses using direct active coping with stressors (e.g., changing the stressor, confronting the stressor, finding positive aspects in the situation) had the lowest burnout scores. It is time for all nurses to turn their impotent festering anger into productive problem-solving action (Thomas, 1998b). Here is an example of psychiatric nurses transforming a workplace: As the nurses themselves described their situation, they were part of a "fiercely patriarchal and autocratic hospital culture" (Breda et al., 1997, p. 77). Fortunately, they understood that if changes were to occur, their own actions would have to be the catalyst, so a small group of nurses undertook a project to increase the autonomy of the 92 APNA website: www.apna.org
nurses there. The project involved a number of elements, including formation of a study group to prepare for certification, incorporation of new holistic healing interventions into their practice, presentation of educational sessions and retreats for the staff, and increased participation in multidisciplinary teams. From an oppressed group, the nurses evolved to b e c o m e increasingly confident, outspoken, and articulate: The...project allowed us to experience a new sense of dignity about ourselves as professionals, which we call "ownership of practice." Ownership of practice includes many of the dimensions of a u t o n o m y - - c o n t r o l over our practice, the freedom to make decisions, and the quality of professional exchange with colleagues that we always sought .... Above all, we developed a firm sense of making a difference with clients and within the organization as a whole. We had become secure in our knowledge base and were no longer willing to be subordinated by others. We recognized that autonomy is linked to power and that the many limits placed on our practice were simply a way to keep nurses in line. (Breda et al., 1997, p. 79) These nurses were experiencing a healthy sense of power. However, many nurses are not comfortable with seeking p o w e r - - a n o t h e r banana peel that can cause slippage at a time w h e n mobilizing their power is critical for APPNs. Power is essential to advocate for vulnerable clients and for our own usefulness in profit-driven managed care systems. However, power and caring have been viewed as antithetical by many nurses. Rafael (1996) p r o p o s e d a new view of CARE (Credentials, Association, Research, and Expertise) so that nurses can accomplish empowered caring. APPNs already have credentials (graduate degrees, certifications) 'that confer credibility. We also have considerable expertise, developed within the rich tradition of clinical scholarship initiated by our founding mother, Hildegard Peplau. However, we fall short in the areas of association and research. By association, Rafael means working with other nurses in professional organizations, as well as aligning with powerful political figures. Psychiatric nursing has p r o d u c e d some notable national leaders, including Peplau, the only individual ever to serve as both president and executive director of ANA; ANA past presidents Lucille Joel and Virginia Betts; and the current ANA president,
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Beverly Malone. However, not enough specialists in psychiatric/mental health nursing are actively involved in organizations, and the multiplicity of organizations competing for their dues dollars is a significant hindrance to unity.
Achievement of Collegial Unity Collegial unity is essential for addressing the challenges we face. It is an old truism that there is strength in numbers. We must present a coherent lobbying agenda for mental health nursing to policymakers and legislators. For example, we should be working together to seek
Power is essential to advocate for vulnerable clients and for our own usefulness in profit-driven managed care systems. Medicaid reimbursement. Currently, Medicaid reimburses only certified pediatric nurse practitioners, certified family nurse practitioners, and certified nurse midwives. Legislation has been introduced in both the House of Representatives (H.R. 1354) and the Senate (S. 1326) to provide Medicaid reimbursement to all NPs and CNSs. This legislation could enable APPNs to serve millions of unserved inner-city and rural residents who need mental health care. However, our specialty has no unified voice. I thought that it was an excellent idea to merge three psychiatric nursing organizations--SERPN, International Society of Psychiatric Consultation Liaison Nurses (ISPCLN), and Association of Child and Adolescent Psychiatric Nurses (ACAPN)--into one, subsequently n a m e d the International Society of Psychiatric-Mental Health Nurses (ISPN). This new organization was ratified by the boards and memberships of all three groups in June 1998. Unfortunately, the American Psychiatric Nurses Association remains separate from the International Society of PsychiatricMental Health Nurses. How many organizations make sense for one nursing specialty? O n c e again, there may be unnecessary splintering of the specialty's talents and energies, a banana peel of our own creation.
Understanding the Nature of Transitions The specialty of psychiatric nursing, like all of nursing, is in a time of transition. Transitions are always diffiJune i9 9 9
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cult and are more so when they occur suddenly and without choice. Psychiatric nurses thrust into the primary care world face an uncomfortable culture clash. For example, the lengthy assessment process of psychiatric specialists, with its careful attention to establishment of trust and rapport with clients, is devalued in a primary care culture that emphasizes speed in evaluation (Chafetz & Bride, 1998). However, we must learn to survive and thrive in this new world, because that is where our clients are. More than 70% of all patients with diagnosed mental health disorders are never seen by a mental health professional and are treated only in primary care (McDaniel et al., cited in Cotroneo, Outlaw, King, & Brince, 1998). We can never go back to the way things were. What can we glean from research about transitions? Levinson (1978, 1996) completed one of the best empirical examinations of life transitions. Through in-depth study of the lives of men and women, he learned that the life structure evolves through a sequence of alternating stable periods and transitional periods. Each of the transitional periods lasts about 5 years. Therefore, if you tally up these periods, almost half our adult lives is spent in transition (Levinson, 1996). I believe Levinson's research should give us a healthier perspective on disruptive change: it is inevitable, it is predictable, and it is surmountable. Most of us grow in c o m p e t e n c e and ego strength because of these periods of turmoil and questioning.
Revising Career Trajectories Many nurses are job-scared, especially those w h o have been watching colleagues in CNS positions get pink slips during hospital downsizing. Although hospital jobs are decreasing, future practice options and sites are proliferating. Psychiatric nurses must revise career trajectories and avail themselves of opportunities in school health, eldercare, and the workplace. Opportunities will soon abound in telemental health, which is expected to be a major component of psychological service delivery in the next millennium, improving access of isolated, and rural clients to therapy. I believe that a heyday for nurse entrepreneurs is coming. More and more nurses will be presidents of their own businesses, from hospices and adult day care establishments to holistic healing centers and consulting firms of all types (Thomas, 1998b). As Dreher (1996) points out, "It is essential to make the distinction between your job and your career....A job is not a career; rather, it is just the vehicle through APNA webs#e: www.apna.org 93
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which we express our career goals. If it no longer holds the possibility for doing that, it probably is time to look for or create a new vehicle" (p. 7). The word "create" in that last sentence is crucial. The mindset of the APPN of the 21st century must be one of innovation. Seizing opportunities to create new positions and roles will be crucial to the survival of psychiatric/mental health nursing.
Marketing Ourselves Clearly, many employers are not aware of what the APPN can offer with regard to screening, assessment, therapeutic management, case management, and prescriptive privileges (ANA, 1998). They may not know that the holistic philosophy of nurses mandates that we are more than "Prozac dispensers" (Jones, 1998), committed to thoughtfully considering our clients' bodies, minds, and spirits as well as the environmental contexts in which they struggle to live and work. Employers may not k n o w that psychiatric/mental health nurses are adept in family, group, and community interventions, unlike many other providers whose expertise is mainly in provision of individual psychotherapy. Strengths that psychiatric nurses bring to the primary care arena include their biopsychosocial orientation, ability to collaborate across professions, experience as client educators and advocates, and history of independent practice (Cotroneo et al., 1998). How will employers learn about our qualifications and capabilities unless we tell them? Perhaps because of archaic admonitions regarding feminine modesty, the predominantly female nursing profession has b e e n slow to incorporate effective self-marketing principles. We can no longer afford misguided reticence about what we know and do. Research makes visible what nurses do (Rafael, 1996). Clearly, the foremost mandate for psychiatric/mental health nursing research is documentation of effective interventions with regard to client symptom reduction, improved function and quality of life, and decreased family burden. The nursing interventions that are "core" to each clinical specialty (i.e., central to defining the nature of the specialty) have already been identified by the Nursing Interventions Classification project at the University of Iowa (McCloskey, Bulechek, & Donahue, 1998). More than 40 interventions are commonly performed by special L ists in psychiatric/mental health nursing. Hallucination management, eating disorders management, cognitive restructuring, c o m p l e x relationship building, and 94 APNA website: www.apna.org
impulse control training are illustrative items from the Nursing Interventions Classification list. Many research questions have yet to be answered about these interventions. When should the intervention be used? When is it contraindicated? Should it be delivered in conjunction with other nursing and/or medical interventions? Should it be delivered antecedent to, along with, or following psychotropic medication? Must it be delivered to individuals, or could it be successfully used with families and groups? What does it cost? What specific outcomes can be predicted, and h o w can they be measured? What is the "nurse dose" needed to show an effect on patient outcomes? It is disturbing that one third of the respondents to the SERPN survey did not use any outcome measures to evaluate
Psychiatric nurses must revise career trajectories and avail themselves of opportunities M school health, eldercare, and the workplace. the effectiveness of their interventions (Barrell, Merwin, & Poster, 1997). If our best-educated practitioners (90.3% of the specialists were master's prepared and 8% were doctorally prepared) have no data to d o c u m e n t the quality and effectiveness of their care, what data can we show to legislators and policymakers to support removal of the constraints to advanced practice? Practicing nurses' priorities were identified in a Delphi survey conducted by Davidson, Merritt-Gray, Buchanan, and Noel (1997), who developed an excellent list of research questions. Their list included: What approaches are most effective for patients w h o frequently use the system with minimal outcome? How is client outcome affected by the availability of a 24-hour crisis service? H o w have budget cutbacks affected the quality and level of client care? What factors influence the burnout of mental health nurses after 5 to 10 years of practice? McBride (1996) asserts that psychiatric nursing research should be particularly concerned with h o w to care for the persistently mentally ill. She points out that even if a cure for schizophrenia appears tomorrow, millions of people will n e e d rehabilitation. In addition, they will still n e e d support from caregivers as they negotiate the challenges of living that reVol. 5, No. 3
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main after the disease process is reversed. Psychiatric nurses care about these patients with a passion unmatched by any other group of providers. Where is the research to d o c u m e n t our effectiveness with this client population? Finding the answers to questions such as these can keep us busy well into the 21st century.
CONCLUSION Futurists are bombarding us with their prognostications as the new millennium approaches. Columbia University's Eli Ginsberg asserts that m a n a g e d care cannot sustain its current growth and industry domi-
It is incumbent upon mental health nurses to demonstrate our unique expertise and value as the dizzying changes in the health care system continue. nance. Furthermore, it will be unable to answer the needs of the American people for universal coverage, sustainable financing, and better care (Ginzberg, 1997). Public concern has grown into a strong backlash against the profit-oriented practices of managed care plans. Consequently, legislation aimed at regulating managed care to protect patients has been introd u c e d in nearly every state. On the federal level, efforts continue to achieve passage of the Patient Safety Act that was first introduced in 1996. Concerns of professionals about ethical dilemmas in managed care settings led to the August 1998 release of an important d o c u m e n t by the National Academies of Practice (which includes the academies of medicine, nursing, psychology, and seven other professions). This document, "Ethical Guidelines for Professional Care and Services in a Managed Health Care Environment," asserts in part, "It is the position of the National Academies of Practice that it is unethical to compromise a patient's needs and quality care concerns to satisfy financial objectives. The patient's right to appropriate care must not be diluted by economic pressures" ("Ethical Guidelines," 1998, p. 2). Ironically, Ginzberg has exposed the fallacy that managed care is cutting costs. During the years of managed care's rapid ascendance, health care costs have not decreased but June I999
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rather quadrupled (from $250 billion in 1980 to $1 trillion in 1995). Hence, convulsive restructuring and reconfiguring of the health care delivery system will continue. Merger mania is n o w evident in the managed care area, with large managed care organizations (MCOs) acquiring smaller MCOs and the larger MCOs merging. Integrated delivery systems are sweeping the United States along with this merger mania. Mental health nurses must be proactive in developing strategies for adaptation to these trends. Spiraling costs must be contained, but patients' rights must not be abrogated in the process. Many experts envision a bright future for nursing. For example, Buerhaus predicts that the value of nurses will rise over the next 10 years (Buerhaus, cited in Nursing Leadership in the 21st Century, 1996). Wykle foresees the nurse of the future as the "hub in the wheel" as manager and coordinator of all providers instrumental in promoting the health of the population (Wykle, cited in Nursing Leadership for the 21st Century, 1996). It is incumbent u p o n mental health nurses to demonstrate our unique expertise and value as the dizzying changes in the health care system continue. When psychiatric nurses stride forward to the n e w millennium with confident proactive steps, no banana peels can cause them to slip.
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