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The community as the site for psychiatric-mental health nursing clinical practicum
BRIEFS The Community as the Site for Psychiatric-Mental Health Nursing Clinical Practicum JUDITH
E. FORKER,
A community psychiatric mental health clinical practicum was developed in response to recent trends in the delivery of mental health services and to the changing mental health needs of the population. Psychiatric mental health nursing and community health nursing clinical practica were Integrated. This approach provided both depth and breadth of experiences in mental health nursing. Additionally, students were able to meet the mental health needs of clients where the clients are increasingly to be found - - i n the community. (Index words: Nursing, psychiatric, mental health, clinical practicum) J Prof Nuts 4:447-452, 1988. © 1988 by W.B. Saunders Company.
R
ECENT MENTAL HEALTH legislation has limited the federal government's previously strong role in the provision of mental health services. In 1978, the Presidential Commission on Mental Health recommended: (1) federal financial support for mental health services and training of personnel; (2) coordination of mental health services with other health service agencies and community support systems; and (3) commitment to meeting the needs of the chronically mentally ill.* However, these recommendations were never fully implemented and in 1981, the Omnibus Reconciliation Act shifted responsibility to the states for the appropriation of funds for mental health services. Concurrently, financial support was reduced dramatically; the net effect was drastically limited federal support, both financial and philosophical, for mental health care. 2 While mental health care services have decreased, the need for them has increased. Mental illness is the most prevalent health problem of this nation, afflicting over 32 million Americans each year. 3 More people are admitted to hospitals for the treatment of mental disorders than for any other illness. Yet the current trend of deinstitutionalization as a health policy quickly returns patients to the community, most often with the same problems that precipi*Assistant Professor, School of Nursing, University of North Carolina-Chapel Hill, Ch'ipel Hill, North Carolina. Address correspondence and reprint requests to Dr Forker: 875 Washington St, Raleigh, NC 27605. © 1988 by W.B. Saunders Company. 8755-7223/88/0406-0015 $ 3.00/0
Journal of ProfessionalNursing, Vol
PHD,
RN,
CS*
tated their hospitalization in the first place. Shorter hospitalization and an increase in readmissions have created a revolving-door syndrome with a chronically ill, dependent population that returns to the hospital after failing to adjust in a community that provides inadequate systematized care.4, 5 In the last 20 years, the scope of psychiatric nursing practice has changed as the mental health needs of the population have increased and the capability of care has decreased. The burden of providing mental health care now lies on the community. Since the 1960s, psychiatric nurses have been an integral part of mental health teams in community mental health centers. With the current restraints on the capabilities of these community agencies to meet mental health needs, mental health nurses must focus interventions on the population at risk, the chronically ill, deinstitutionalized patients, as well as on prevention of mental illness and on mental healih maintenance. Today, the mental health delivery system .is so burdened that many patients are lost in an inadequate system thathas neither the funds nor the personnel to meet their needs. Ideally, as McCausland e suggests, psychiatric nurse leaders and researchers should create model treatment programs to serve the needs of the mentally ill in the community. However, until such programs are developed, psychiatric nurses, along with other health care providers, must concentrate on maintaining as many patients as possible at adequate levels of functioning. In a 1985 study by Weissman v of five metropolitan catchment areas, approximately 14 per cent of the men and 12 per cent of the women studied experienced a DSM-III Axis I disorder in a 6-month period. Fewer than 20 per cent of these individuals had sought treatment from a mental health professional in the 6 months before the study. The implication is clear: although a significant number of people suffer mental impairment, few seek treatment. The community health nurse generalist must be able to identify those in need of service and to provide supportive care or to facilitate treatment in the appropriate agency. It is the responsibility of nursing educators to prepare students to practice effectively within the constraints of a system that is limited in its ability to meet a community's mental health needs. As a result of the current decrease in mental health services, prevention, maintenance, and postdischarge follow-up in the community become vital. Be-
4, N o 6 ( N o v e m b e r - D e c e m b e r ) , 1988: p p 4 4 7 - 4 5 2
447
448 cause nurses' roles within the system must change to meet these needs, the focus and context of students' clinical learning experiences must change. Inpatient experiences in psychiatric nursing allow access to one aspect of client's overall experience. With the trend toward shorter periods of hospitalization, most care is provided within the community. Therefore, the community is increasingly important in mental health clinical experiences for baccalaureate students. The integration of mental health and c o m m u n i t y nursing occurred in baccalaureate nursing curricula as early as the 1960s, when the Community Mental Health Centers Act of 1963 supported care and rehabilitation of the mentally ill in the community. But the lack of integration of community systems with hospital systems over the last 25 years has created serious problems in the delivery of mental health care to the population, s An integrated approach to teaching mental health nursing is made more difficult by the limitations of the mental health care delivery system. The lack of coordination in the larger system may in part explain the cyclic nature of mental health-community health nursing integration. However, with the current vital need for mental health services in the community, nursing educators are again considering an integrative approach to teaching the two disciplines. At one university-based baccalaureate program, the school of nursing has responded to these needs by altering the undergraduate mental health clinical practicum to offer students either an inpatient setting or a community setting for their clinical learning experience. For selected students, the psychiatric nursing clinical practicum is integrated with the community health nursing clinical practicum. Both community health and psychiatric nursing clinical objectives are met in the same semester. This approach is compatible with the community health nursing course, which has always included a strong mental health component. Currently, students gain access to DSM-III-diagnosed psychiatric clients through the public health agency or community clinical site. The integration of these two clinical experiences enhances students' learning by emphasizing a holistic approach to community health while providing the opportunity for mental health clinical experience in the client's home. The mental health milieu becomes home, family, and community rather than hospital, and the mental health needs of clients are emphasized within the context of a generalist community health practicum. Implementation of the integrated clinical practicum calls for competent, experienced faculty members to identify, plan, and coordinate students' learning experiences. In the combined practicum, nursing knowledge and practice of both disciplines are integrated so that students not only learn the essentials of each but also learn to synthesize the two disciplines to provide a high level of nursing care. Establishing learning opportunities in the various clinical sites demands expertise, time, and energy. This is an ongoing process between nursing faculty and the community agencies. In the planning and implementation of a new approach to clinical practicum, faculty members must consider the current demands on the particular agency's resources in terms of provision of health services, personnel needs, and workload stresses. As the relationship between
JUDITH E. FORKER
the nursing school and the community agencies develop and change over time, the faculty must continue to be responsive to the needs of both the school of nursing and the agencies with which it collaborates. C o m m u n i t y Health-Mental Health Nursing Sites
Undergraduate baccalaureate students are assigned to existing community health nursing clinical facilities for their community health-mental health nursing experience. Currently, these include a county health department and an area mental health, mental retardation, and substance abuse authority; out-patient clinics at a large county hospital; and a community geriatric nursing practice. Each of the sites currently used for the program is described below, and opportunities unique to each site are discussed. COUNTY HEALTH DEPARTMENT AND AREA MENTAL HEALTH, MENTAL RETARDATION, AND SUBSTANCE ABUSE AUTHORITY
At this clinical site the county health department and mental health center are next door to each other, affording students easy access to each facility's resources. Two instructors are assigned to the site. Each student spends one day each week in the health department with one instructor and one day in the mental health center with the other instructor. Together the instructors coordinate the community health and the mental health experiences for each student. At the mental health center, students have access to clients in several different programs. They form one-to-one relationships with clients and participate in ongoing groups as well. Currefitly, students may participate in (1) education and remotivation groups run by the mental health center's nurses for the chronically mentaUy ill and patients recently discharged from a state mental hospital; (2) domestic violence program; (3) the county prison unit, where substance abuse treatment groups are conducted by students and ongoing one-to-one interaction with clients is provided; (4) rest homes where the mentally ill reside; (5) several junior high and high school mental health primary prevention programs; and (6) outpatient alcohol treatment groups. For future semesters at this site, the faculty members and psychiatric mental health nurses are planning to expand and further develop the experiences in the remotivation groups, the rest homes, and the after-care program, which promises an excellent opportunity for students to evaluate and interact with recently discharged patients. One important and valuable aspect of these experiences is that the community mental health nurse is actively involved with the student as a role model and a collaborator in the provision of patient care. For example, students may observe the nurses' group skills, test their own skills, and develop skills through direct feedback. All of the clients are also in the one-to-one caseloads of the mental health nurst~, so the students' one-to-one practice with clients can be enriched by a nurse role model who has direct knowledge of each client's needs. COUNTY CLINICS
Students at this site are assigned clients from the caseload at the clinics. This setting has a variety of clients and opportunities for students to integrate psychiatric nursing with community health nursing. Each student follows
449
PSYCHIATRIC-MENTAL HEALTH NURSING
three to five psychiatric-diagnosed clients over the course of the semester. Daily clinical conferences further expose students to the range of client problems and, through case presentations, to the multifaceted needs of each client. Additionally, students are able to attend team conferences and to consult and collaborate with mental health professionals from other disciplines.
COUNTYHEALTHDEPARTMENT At this clinical site students have access to psychiatricmental health clients from the health department caseload. Here it is not possible to coordinate experiences with the county mental health center; because of expansion of the center's programs and subsequent stress on personnel, use of the center was delayed for one semester. Although it is still possible for students to develop therapeutic relationshii~s with DSM III-diagnosed clients, it is more difficult to gain access to these clients, as most of them are carried in the health department caseload for physical rather than emotional problems. Additionally, student involvement with a mental health treatment team at this site is not currently possible. Supplementary experiences such as assignment to clients in rest homes, participatory visits to the state psychiatric hospital, and attendance at team conferences on psychiatric unit~ at a university hospital are provided to add breadth to these experiences.
COMMUNITYGERIATRICNURSINGPRACTICE A community geriatric nursing practice developed by one community health nursing faculty member provides a clinical practicum for eight students. Each student works with seven or eight clients, three of whom are DSM IIIdiagnosed, for the semester. The continuity afforded through weekly or biweekly home visits for 14 weeks allows students to build in-depth relationships with clients and their families. The opportunity for family assessment and intervention in a psychiatric mental health nursing clinical experience is extremely valuable for students. They gain insight into the clients' experiences, apply family theory to practice, and coordinate care within the family system. The major focus of the faculty at this site is to assist students in applying psychiatric nursing theory in each step of the nursing process. This goal is accomplished in two individual weekly conferences with each student--one with the community health nursing instructor and one with the psychiatric nursing instructor. The community health faculty member makes a minimum of two home visits with each student per client, one visit during the first half of the semester and one during the second half. The mental health instructor also makes home visits with students for supervision and role-modeling. Weekly group conferences with both faculty and written feedback are also essential aspects of this learning experience. The community geriatric nursing practice is a nontraditional clinical site for both psychiatric nursing and community health nursing. The community agency is not an institution, yet the experiences available within the framework of the community practice provide essential knowledge and skills for both areas of nursing practice. Additionally, this site offers a degree of continuity and a depth
of client interaction that contribute much to the quality of the learning experience.
Variation in Client Diagnosis in the Community Setting In planning and implementing a community approach to psychiatric nursing clinical experience, a major concern has been gaining access to adequate numbers of D S M - I I I diagnosed clients to assign to students at each community health site. A sufficient number of clients must be available for students to develop nurse-client relationships with a minimum of one, and ideally with several, clients over the course of the semester. To assess the type and numbers of DSM-III-diagnosed clients available for assignment to student caseloads,.data were collected during fall 1986 and spring 1987. To determine if there were basic differences in student exposure to clients with different diagnoses in the inpatient and the community settings during the same period, data also were collected on student assignments in psychiatric in-patient settings. The diagnoses of clients assigned to students in each community health site during the semesters are represented in Table 1. Depressive disorders were the most prevalent diagnoses in three of the four settings; and adjustment disorders were also well represented. The third and fourth most frequent diagnoses were substance abuse and organic mental disorders. The range of client diagnoses at each community health clinical site was wide. Students were able to develop one-to-one relationships with one to five clients with different diagnoses. Furthermore, within clinical groups the variation in mental disorders among clients followed by students enriched group presentations and group supervision experiences for all students. Client assignment data were also compared with corresponding data on student assignments in inpatient clinical settings (Table 2). As in the community, the clients most frequently assigned to students in hospital settings were those with depressive disorders. Clients with other mental disorders such as bipolar, schizophrenic, and paranoid disorders, which were well represented in inpatient settings, were present but less frequent at the community sites. However, clients with adjustment, personality, and sexual disorders were more frequent in community settings. Although the frequency of diagnoses varied somewhat from inpatient to community sites, these differences were anticipated. Additionally, data were available from the Division of Mental Health, Mental Retardation, and Substance Abuse Services on the numbers of persons served within each d%gnostic category in mental health programs in North Carolina (Table 2). Again, as one would expect, the diagnoses most frequently represented in the community psychiatric nursing assignments were also the ones most frequently treated through mental health service programs in the state.
Psychiatric Nursing Experiences Available at Community Health Sites The opportunity to develop a therapeutic nurse-client relationship with a client diagnosed according to the DSM-III classification was basic to each student's psychi-
450 TABLE 1.
JUDITH E. FORKER D S M - I I I D i a g n o s e s o f C l i e n t s A s s i g n e d to S t u d e n t s in C o m m u n i t y
DSM-Itl DLsorder Attention deficit Schizophrenic Paranoid Other psychotic Bipolar Depressive Anxiety. Sexual Personality Adjustment Social conduct Organic mental Eating Mental retardation Substance abuse Factitious Impulsive
County Clinics (16 Students)
Health Nursing Sites
Health Department/ Mental Health Department (11 Students)
Community Geriatric Practice (8 Students)
County Health Department (11 Students)
1 1
3
1 1
4 1 1 1 3 15 4 5 5 14 1 7 1 1 5
1 2 1
14 4 1 3 1
2 1
Data presented are based on 1:1 student-to-client relationships, with a minimum of five interactions in the 1986-1987 academic year.
atric nursing clinical-experience. This relationship often extended over a 14-week period. The client was seen at least once each week, although in many cases the students visited twice a week. ,Through one-to-one relationships, students had the opportunity to apply essential psychiatric nursing knowledge, to learn clinical judgment, and to practice intervention skills. Whenever possible, both the individual client and the family were included in the plan TABLE 2.
of care. Faculty supervision, home visits with each student, and group clinical conferences assisted the students in the learning process. Furthermore, group clinical conferences allowed the opportunity to learn through sharing experiences and through giving and receiving feedback on nursing care of clients whose diagnostic syndromes differed. Thus, the students learned from each other's experiences with the nursing care of psychiatric clients.
C l i e n t D i a g n o s e s in S e l e c t e d T r e a t m e n t S e t t i n g s
DSM-III Disorder Attention deficit Schizophrenic Paranoid Other psychotic Bipolar Depressive Anxiety Somatoform Dissociative Sexual Personality Adjustment Social conduct Organic mental Eating Mental retardation Substance abuse Factitious Impulsive Total clients Total students
Psychiatric Nursing: Community Sites"
Psychiatric Nursing: Inpatient Sites'l"
Persons Served in State (NC) Programs:l:
4 3 6 1 4 39 9
6 17 1 I 10 34
6 10 18 2 16 2 3 12 1 1
1
124 948 70 155 527 1371 224 35 6 28 236 1569 576 49 15 632 5177
136 46
*Community health nursing sites, fall 1986 and spring 1987. 1Psychiatric nursing inpatient sites, fall 1986 and spring 1987. :l:Selected counties, July 1, 1985 to June 30, 1986.9
1 1 1 2
77 51
PSYCHIATRIC-MENTAL HEALTH NURSING
Evaluation and Plans for Enhancing Current Offerings For the 1986-1987 academic year, not all students were able to be involved in all of the learning experiences available through the program. For example, depending on the community health nursing sites, students may have participated in either educational or treatment groups, focused on the family as well as the individual client, or developed theTapeutic relationships with clients in rest homes or nursing homes. Students who were assigned to a mental health depa?tment had a wider variety of treatment approaches and intervention activities. The quality and availability of learning experiences at the mental health department support the use of the health department-mental health department model in clinical learning sites for the community psychiatric nursing experience. Negotiations are currently under way between the faculty and two other county mental health centers housed in the same building as the county health department, for additional clinical learning sites. This will broaden opportunities for all students in the program. A major concern during the first year of implementation was availability of mental health clients for assignment to students. Data from this study suggest that the numbers of clients with psychiatric diagnoses and the range of diagnoses were adequate. In addition to ongoing assessment of this aspect of the program, an evaluation of students' learning outcomes is planned for the next academic year. To assess students' mental health knowledge upon completion of the inpatient and community practica, N-CLEX scores of students assigned to the community will be compared with those in the hospital setting.
Conclusions, Limitations, and Recommendations Based on the findings and observations discussed above, the following conclusions may be drawn: 1. A c o m b i n e d c o m m u n i t y health-psychiatric nursing practicum is a feasible alternative to assignment in an inpatient psychiatric setting, allowing students opportunities to meet the objectives for both courses. 2. Adequate numbers of clients with DSM-III disorders are available for assignment to students in the community. 3. A wide range of diagnostic disorders is accessible in community sites, although they vary from site to site. 4. The community as a setting for a psychiatric nursing practicum offers practice in a broad range of treatment approaches and many opportunities to practice nursing at all levels of prevention. The following limitations are recognized: 1. Students do not routinely have the opportunity to observe and/or interact with clients in the acute phase of a mental illness. 2. Both the student and the faculty member must invest "outreach" energy in the community to
451
gain access to patients, to coordinate services with various agencies, and to collaborate with community health and mental health team members. Considering both the strengths and limitations of the experience over the past year, several actions and/or directions can be recommended: 1. Integration of community health nursing with psychiatric mental health nursing should be continued, providing the following learning opportunities for students: One-to-one nurse-client relationships Access to clients with a range of different DSM-III diagnoses Family and group intervention experiences Practice directed toward all levels of prevention Access to clients in a variety of treatment settings Continued close supervision and instruction by both mental health and community health faculty members. 2. The current program should be enhanced and developed in the following ways: Use of both health departments and mental health departments at each clinical site to afford greater and wider access to clients and to mental health treatment approaches. Increased student contact with recently discharged clients who need follow-up care through aftercare programs Opportunity for all students to interact with mental health treatment teams Opportunities for practice in collaboration with mental health nurses who would serve as role models for the students Evaluation of learning outcomes of students in this program and comparison with students assigned to traditional in-hospital sites In summary, the community health and psychiatric nursing experience has proven to be a sound and feasible method for providing a clinical practicum in psychiatric nursing. The faculty members are encouraged by both the depth and breadth of experiences available to students in the community. We believe that this approach will prepare students well for practice, enabling them to meet the mental health needs of clients in the places clients increasingly are to be f o u n d - - a t home, with the family, and in the community.
References 1. President's Commission on Mental Health: Report to the President, vol 1. \Vashington, DC, Government Printing Office, 1978, pp 9-10 2. Hendrix M, Hughes T: Rural community mental health nursing. In Burgess A (ed): Psychiatric Nursing in the Hospital and the Community. Englewood Cliffs, NJ, Prentice-Hall, 1985, pp 899-906 3. Facklemann K.: Perspectives: A fragmented mental health system. Med Health 40:41, 1986 4. Steering Committee on the Chronically Mentally Ill: Toward a national plan for the chronically mentally ill: A report to
452 the secretary. US Department of Health and Human Services, Publ No. 81-1077. Washington, DC, Government Printing Ofrice, 1981 5. Slavinsky A: Psychiatric nursing in the year 2000: From a nonsystem of care to a coding system. Image 16:17-20, 1984 6. McCausland M: Deinstitutionalizationof the mentally ill: Oversimplification of complex issues. Adv Nuts Sci 9:24-33, 1987
JUDITH E. FORKER
7. Weissman M: Advances in psychiatric epidemiology: Rates and risks for major depression. Am J Public Health 77:445-451, 1987 8. Worley N, Lowrey B: Deinstitutionalization: Could the process have been better for patients? Arch Psychiatr Nuts 2:126131, 1988 9. North Carolina Division of Mental Health, Mental Retardation, and Substance Abuse Services: Data from selected counties, July 1, 1985 to June 30, 1986
E. FORKER,
A community psychiatric mental health clinical practicum was developed in response to recent trends in the delivery of mental health services and to the changing mental health needs of the population. Psychiatric mental health nursing and community health nursing clinical practica were Integrated. This approach provided both depth and breadth of experiences in mental health nursing. Additionally, students were able to meet the mental health needs of clients where the clients are increasingly to be found - - i n the community. (Index words: Nursing, psychiatric, mental health, clinical practicum) J Prof Nuts 4:447-452, 1988. © 1988 by W.B. Saunders Company.
R
ECENT MENTAL HEALTH legislation has limited the federal government's previously strong role in the provision of mental health services. In 1978, the Presidential Commission on Mental Health recommended: (1) federal financial support for mental health services and training of personnel; (2) coordination of mental health services with other health service agencies and community support systems; and (3) commitment to meeting the needs of the chronically mentally ill.* However, these recommendations were never fully implemented and in 1981, the Omnibus Reconciliation Act shifted responsibility to the states for the appropriation of funds for mental health services. Concurrently, financial support was reduced dramatically; the net effect was drastically limited federal support, both financial and philosophical, for mental health care. 2 While mental health care services have decreased, the need for them has increased. Mental illness is the most prevalent health problem of this nation, afflicting over 32 million Americans each year. 3 More people are admitted to hospitals for the treatment of mental disorders than for any other illness. Yet the current trend of deinstitutionalization as a health policy quickly returns patients to the community, most often with the same problems that precipi*Assistant Professor, School of Nursing, University of North Carolina-Chapel Hill, Ch'ipel Hill, North Carolina. Address correspondence and reprint requests to Dr Forker: 875 Washington St, Raleigh, NC 27605. © 1988 by W.B. Saunders Company. 8755-7223/88/0406-0015 $ 3.00/0
Journal of ProfessionalNursing, Vol
PHD,
RN,
CS*
tated their hospitalization in the first place. Shorter hospitalization and an increase in readmissions have created a revolving-door syndrome with a chronically ill, dependent population that returns to the hospital after failing to adjust in a community that provides inadequate systematized care.4, 5 In the last 20 years, the scope of psychiatric nursing practice has changed as the mental health needs of the population have increased and the capability of care has decreased. The burden of providing mental health care now lies on the community. Since the 1960s, psychiatric nurses have been an integral part of mental health teams in community mental health centers. With the current restraints on the capabilities of these community agencies to meet mental health needs, mental health nurses must focus interventions on the population at risk, the chronically ill, deinstitutionalized patients, as well as on prevention of mental illness and on mental healih maintenance. Today, the mental health delivery system .is so burdened that many patients are lost in an inadequate system thathas neither the funds nor the personnel to meet their needs. Ideally, as McCausland e suggests, psychiatric nurse leaders and researchers should create model treatment programs to serve the needs of the mentally ill in the community. However, until such programs are developed, psychiatric nurses, along with other health care providers, must concentrate on maintaining as many patients as possible at adequate levels of functioning. In a 1985 study by Weissman v of five metropolitan catchment areas, approximately 14 per cent of the men and 12 per cent of the women studied experienced a DSM-III Axis I disorder in a 6-month period. Fewer than 20 per cent of these individuals had sought treatment from a mental health professional in the 6 months before the study. The implication is clear: although a significant number of people suffer mental impairment, few seek treatment. The community health nurse generalist must be able to identify those in need of service and to provide supportive care or to facilitate treatment in the appropriate agency. It is the responsibility of nursing educators to prepare students to practice effectively within the constraints of a system that is limited in its ability to meet a community's mental health needs. As a result of the current decrease in mental health services, prevention, maintenance, and postdischarge follow-up in the community become vital. Be-
4, N o 6 ( N o v e m b e r - D e c e m b e r ) , 1988: p p 4 4 7 - 4 5 2
447
448 cause nurses' roles within the system must change to meet these needs, the focus and context of students' clinical learning experiences must change. Inpatient experiences in psychiatric nursing allow access to one aspect of client's overall experience. With the trend toward shorter periods of hospitalization, most care is provided within the community. Therefore, the community is increasingly important in mental health clinical experiences for baccalaureate students. The integration of mental health and c o m m u n i t y nursing occurred in baccalaureate nursing curricula as early as the 1960s, when the Community Mental Health Centers Act of 1963 supported care and rehabilitation of the mentally ill in the community. But the lack of integration of community systems with hospital systems over the last 25 years has created serious problems in the delivery of mental health care to the population, s An integrated approach to teaching mental health nursing is made more difficult by the limitations of the mental health care delivery system. The lack of coordination in the larger system may in part explain the cyclic nature of mental health-community health nursing integration. However, with the current vital need for mental health services in the community, nursing educators are again considering an integrative approach to teaching the two disciplines. At one university-based baccalaureate program, the school of nursing has responded to these needs by altering the undergraduate mental health clinical practicum to offer students either an inpatient setting or a community setting for their clinical learning experience. For selected students, the psychiatric nursing clinical practicum is integrated with the community health nursing clinical practicum. Both community health and psychiatric nursing clinical objectives are met in the same semester. This approach is compatible with the community health nursing course, which has always included a strong mental health component. Currently, students gain access to DSM-III-diagnosed psychiatric clients through the public health agency or community clinical site. The integration of these two clinical experiences enhances students' learning by emphasizing a holistic approach to community health while providing the opportunity for mental health clinical experience in the client's home. The mental health milieu becomes home, family, and community rather than hospital, and the mental health needs of clients are emphasized within the context of a generalist community health practicum. Implementation of the integrated clinical practicum calls for competent, experienced faculty members to identify, plan, and coordinate students' learning experiences. In the combined practicum, nursing knowledge and practice of both disciplines are integrated so that students not only learn the essentials of each but also learn to synthesize the two disciplines to provide a high level of nursing care. Establishing learning opportunities in the various clinical sites demands expertise, time, and energy. This is an ongoing process between nursing faculty and the community agencies. In the planning and implementation of a new approach to clinical practicum, faculty members must consider the current demands on the particular agency's resources in terms of provision of health services, personnel needs, and workload stresses. As the relationship between
JUDITH E. FORKER
the nursing school and the community agencies develop and change over time, the faculty must continue to be responsive to the needs of both the school of nursing and the agencies with which it collaborates. C o m m u n i t y Health-Mental Health Nursing Sites
Undergraduate baccalaureate students are assigned to existing community health nursing clinical facilities for their community health-mental health nursing experience. Currently, these include a county health department and an area mental health, mental retardation, and substance abuse authority; out-patient clinics at a large county hospital; and a community geriatric nursing practice. Each of the sites currently used for the program is described below, and opportunities unique to each site are discussed. COUNTY HEALTH DEPARTMENT AND AREA MENTAL HEALTH, MENTAL RETARDATION, AND SUBSTANCE ABUSE AUTHORITY
At this clinical site the county health department and mental health center are next door to each other, affording students easy access to each facility's resources. Two instructors are assigned to the site. Each student spends one day each week in the health department with one instructor and one day in the mental health center with the other instructor. Together the instructors coordinate the community health and the mental health experiences for each student. At the mental health center, students have access to clients in several different programs. They form one-to-one relationships with clients and participate in ongoing groups as well. Currefitly, students may participate in (1) education and remotivation groups run by the mental health center's nurses for the chronically mentaUy ill and patients recently discharged from a state mental hospital; (2) domestic violence program; (3) the county prison unit, where substance abuse treatment groups are conducted by students and ongoing one-to-one interaction with clients is provided; (4) rest homes where the mentally ill reside; (5) several junior high and high school mental health primary prevention programs; and (6) outpatient alcohol treatment groups. For future semesters at this site, the faculty members and psychiatric mental health nurses are planning to expand and further develop the experiences in the remotivation groups, the rest homes, and the after-care program, which promises an excellent opportunity for students to evaluate and interact with recently discharged patients. One important and valuable aspect of these experiences is that the community mental health nurse is actively involved with the student as a role model and a collaborator in the provision of patient care. For example, students may observe the nurses' group skills, test their own skills, and develop skills through direct feedback. All of the clients are also in the one-to-one caseloads of the mental health nurst~, so the students' one-to-one practice with clients can be enriched by a nurse role model who has direct knowledge of each client's needs. COUNTY CLINICS
Students at this site are assigned clients from the caseload at the clinics. This setting has a variety of clients and opportunities for students to integrate psychiatric nursing with community health nursing. Each student follows
449
PSYCHIATRIC-MENTAL HEALTH NURSING
three to five psychiatric-diagnosed clients over the course of the semester. Daily clinical conferences further expose students to the range of client problems and, through case presentations, to the multifaceted needs of each client. Additionally, students are able to attend team conferences and to consult and collaborate with mental health professionals from other disciplines.
COUNTYHEALTHDEPARTMENT At this clinical site students have access to psychiatricmental health clients from the health department caseload. Here it is not possible to coordinate experiences with the county mental health center; because of expansion of the center's programs and subsequent stress on personnel, use of the center was delayed for one semester. Although it is still possible for students to develop therapeutic relationshii~s with DSM III-diagnosed clients, it is more difficult to gain access to these clients, as most of them are carried in the health department caseload for physical rather than emotional problems. Additionally, student involvement with a mental health treatment team at this site is not currently possible. Supplementary experiences such as assignment to clients in rest homes, participatory visits to the state psychiatric hospital, and attendance at team conferences on psychiatric unit~ at a university hospital are provided to add breadth to these experiences.
COMMUNITYGERIATRICNURSINGPRACTICE A community geriatric nursing practice developed by one community health nursing faculty member provides a clinical practicum for eight students. Each student works with seven or eight clients, three of whom are DSM IIIdiagnosed, for the semester. The continuity afforded through weekly or biweekly home visits for 14 weeks allows students to build in-depth relationships with clients and their families. The opportunity for family assessment and intervention in a psychiatric mental health nursing clinical experience is extremely valuable for students. They gain insight into the clients' experiences, apply family theory to practice, and coordinate care within the family system. The major focus of the faculty at this site is to assist students in applying psychiatric nursing theory in each step of the nursing process. This goal is accomplished in two individual weekly conferences with each student--one with the community health nursing instructor and one with the psychiatric nursing instructor. The community health faculty member makes a minimum of two home visits with each student per client, one visit during the first half of the semester and one during the second half. The mental health instructor also makes home visits with students for supervision and role-modeling. Weekly group conferences with both faculty and written feedback are also essential aspects of this learning experience. The community geriatric nursing practice is a nontraditional clinical site for both psychiatric nursing and community health nursing. The community agency is not an institution, yet the experiences available within the framework of the community practice provide essential knowledge and skills for both areas of nursing practice. Additionally, this site offers a degree of continuity and a depth
of client interaction that contribute much to the quality of the learning experience.
Variation in Client Diagnosis in the Community Setting In planning and implementing a community approach to psychiatric nursing clinical experience, a major concern has been gaining access to adequate numbers of D S M - I I I diagnosed clients to assign to students at each community health site. A sufficient number of clients must be available for students to develop nurse-client relationships with a minimum of one, and ideally with several, clients over the course of the semester. To assess the type and numbers of DSM-III-diagnosed clients available for assignment to student caseloads,.data were collected during fall 1986 and spring 1987. To determine if there were basic differences in student exposure to clients with different diagnoses in the inpatient and the community settings during the same period, data also were collected on student assignments in psychiatric in-patient settings. The diagnoses of clients assigned to students in each community health site during the semesters are represented in Table 1. Depressive disorders were the most prevalent diagnoses in three of the four settings; and adjustment disorders were also well represented. The third and fourth most frequent diagnoses were substance abuse and organic mental disorders. The range of client diagnoses at each community health clinical site was wide. Students were able to develop one-to-one relationships with one to five clients with different diagnoses. Furthermore, within clinical groups the variation in mental disorders among clients followed by students enriched group presentations and group supervision experiences for all students. Client assignment data were also compared with corresponding data on student assignments in inpatient clinical settings (Table 2). As in the community, the clients most frequently assigned to students in hospital settings were those with depressive disorders. Clients with other mental disorders such as bipolar, schizophrenic, and paranoid disorders, which were well represented in inpatient settings, were present but less frequent at the community sites. However, clients with adjustment, personality, and sexual disorders were more frequent in community settings. Although the frequency of diagnoses varied somewhat from inpatient to community sites, these differences were anticipated. Additionally, data were available from the Division of Mental Health, Mental Retardation, and Substance Abuse Services on the numbers of persons served within each d%gnostic category in mental health programs in North Carolina (Table 2). Again, as one would expect, the diagnoses most frequently represented in the community psychiatric nursing assignments were also the ones most frequently treated through mental health service programs in the state.
Psychiatric Nursing Experiences Available at Community Health Sites The opportunity to develop a therapeutic nurse-client relationship with a client diagnosed according to the DSM-III classification was basic to each student's psychi-
450 TABLE 1.
JUDITH E. FORKER D S M - I I I D i a g n o s e s o f C l i e n t s A s s i g n e d to S t u d e n t s in C o m m u n i t y
DSM-Itl DLsorder Attention deficit Schizophrenic Paranoid Other psychotic Bipolar Depressive Anxiety. Sexual Personality Adjustment Social conduct Organic mental Eating Mental retardation Substance abuse Factitious Impulsive
County Clinics (16 Students)
Health Nursing Sites
Health Department/ Mental Health Department (11 Students)
Community Geriatric Practice (8 Students)
County Health Department (11 Students)
1 1
3
1 1
4 1 1 1 3 15 4 5 5 14 1 7 1 1 5
1 2 1
14 4 1 3 1
2 1
Data presented are based on 1:1 student-to-client relationships, with a minimum of five interactions in the 1986-1987 academic year.
atric nursing clinical-experience. This relationship often extended over a 14-week period. The client was seen at least once each week, although in many cases the students visited twice a week. ,Through one-to-one relationships, students had the opportunity to apply essential psychiatric nursing knowledge, to learn clinical judgment, and to practice intervention skills. Whenever possible, both the individual client and the family were included in the plan TABLE 2.
of care. Faculty supervision, home visits with each student, and group clinical conferences assisted the students in the learning process. Furthermore, group clinical conferences allowed the opportunity to learn through sharing experiences and through giving and receiving feedback on nursing care of clients whose diagnostic syndromes differed. Thus, the students learned from each other's experiences with the nursing care of psychiatric clients.
C l i e n t D i a g n o s e s in S e l e c t e d T r e a t m e n t S e t t i n g s
DSM-III Disorder Attention deficit Schizophrenic Paranoid Other psychotic Bipolar Depressive Anxiety Somatoform Dissociative Sexual Personality Adjustment Social conduct Organic mental Eating Mental retardation Substance abuse Factitious Impulsive Total clients Total students
Psychiatric Nursing: Community Sites"
Psychiatric Nursing: Inpatient Sites'l"
Persons Served in State (NC) Programs:l:
4 3 6 1 4 39 9
6 17 1 I 10 34
6 10 18 2 16 2 3 12 1 1
1
124 948 70 155 527 1371 224 35 6 28 236 1569 576 49 15 632 5177
136 46
*Community health nursing sites, fall 1986 and spring 1987. 1Psychiatric nursing inpatient sites, fall 1986 and spring 1987. :l:Selected counties, July 1, 1985 to June 30, 1986.9
1 1 1 2
77 51
PSYCHIATRIC-MENTAL HEALTH NURSING
Evaluation and Plans for Enhancing Current Offerings For the 1986-1987 academic year, not all students were able to be involved in all of the learning experiences available through the program. For example, depending on the community health nursing sites, students may have participated in either educational or treatment groups, focused on the family as well as the individual client, or developed theTapeutic relationships with clients in rest homes or nursing homes. Students who were assigned to a mental health depa?tment had a wider variety of treatment approaches and intervention activities. The quality and availability of learning experiences at the mental health department support the use of the health department-mental health department model in clinical learning sites for the community psychiatric nursing experience. Negotiations are currently under way between the faculty and two other county mental health centers housed in the same building as the county health department, for additional clinical learning sites. This will broaden opportunities for all students in the program. A major concern during the first year of implementation was availability of mental health clients for assignment to students. Data from this study suggest that the numbers of clients with psychiatric diagnoses and the range of diagnoses were adequate. In addition to ongoing assessment of this aspect of the program, an evaluation of students' learning outcomes is planned for the next academic year. To assess students' mental health knowledge upon completion of the inpatient and community practica, N-CLEX scores of students assigned to the community will be compared with those in the hospital setting.
Conclusions, Limitations, and Recommendations Based on the findings and observations discussed above, the following conclusions may be drawn: 1. A c o m b i n e d c o m m u n i t y health-psychiatric nursing practicum is a feasible alternative to assignment in an inpatient psychiatric setting, allowing students opportunities to meet the objectives for both courses. 2. Adequate numbers of clients with DSM-III disorders are available for assignment to students in the community. 3. A wide range of diagnostic disorders is accessible in community sites, although they vary from site to site. 4. The community as a setting for a psychiatric nursing practicum offers practice in a broad range of treatment approaches and many opportunities to practice nursing at all levels of prevention. The following limitations are recognized: 1. Students do not routinely have the opportunity to observe and/or interact with clients in the acute phase of a mental illness. 2. Both the student and the faculty member must invest "outreach" energy in the community to
451
gain access to patients, to coordinate services with various agencies, and to collaborate with community health and mental health team members. Considering both the strengths and limitations of the experience over the past year, several actions and/or directions can be recommended: 1. Integration of community health nursing with psychiatric mental health nursing should be continued, providing the following learning opportunities for students: One-to-one nurse-client relationships Access to clients with a range of different DSM-III diagnoses Family and group intervention experiences Practice directed toward all levels of prevention Access to clients in a variety of treatment settings Continued close supervision and instruction by both mental health and community health faculty members. 2. The current program should be enhanced and developed in the following ways: Use of both health departments and mental health departments at each clinical site to afford greater and wider access to clients and to mental health treatment approaches. Increased student contact with recently discharged clients who need follow-up care through aftercare programs Opportunity for all students to interact with mental health treatment teams Opportunities for practice in collaboration with mental health nurses who would serve as role models for the students Evaluation of learning outcomes of students in this program and comparison with students assigned to traditional in-hospital sites In summary, the community health and psychiatric nursing experience has proven to be a sound and feasible method for providing a clinical practicum in psychiatric nursing. The faculty members are encouraged by both the depth and breadth of experiences available to students in the community. We believe that this approach will prepare students well for practice, enabling them to meet the mental health needs of clients in the places clients increasingly are to be f o u n d - - a t home, with the family, and in the community.
References 1. President's Commission on Mental Health: Report to the President, vol 1. \Vashington, DC, Government Printing Office, 1978, pp 9-10 2. Hendrix M, Hughes T: Rural community mental health nursing. In Burgess A (ed): Psychiatric Nursing in the Hospital and the Community. Englewood Cliffs, NJ, Prentice-Hall, 1985, pp 899-906 3. Facklemann K.: Perspectives: A fragmented mental health system. Med Health 40:41, 1986 4. Steering Committee on the Chronically Mentally Ill: Toward a national plan for the chronically mentally ill: A report to
452 the secretary. US Department of Health and Human Services, Publ No. 81-1077. Washington, DC, Government Printing Ofrice, 1981 5. Slavinsky A: Psychiatric nursing in the year 2000: From a nonsystem of care to a coding system. Image 16:17-20, 1984 6. McCausland M: Deinstitutionalizationof the mentally ill: Oversimplification of complex issues. Adv Nuts Sci 9:24-33, 1987
JUDITH E. FORKER
7. Weissman M: Advances in psychiatric epidemiology: Rates and risks for major depression. Am J Public Health 77:445-451, 1987 8. Worley N, Lowrey B: Deinstitutionalization: Could the process have been better for patients? Arch Psychiatr Nuts 2:126131, 1988 9. North Carolina Division of Mental Health, Mental Retardation, and Substance Abuse Services: Data from selected counties, July 1, 1985 to June 30, 1986