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Trends in psychiatric mental health nursing education
Trends in Psychiatric Mental Health Nursing Education Kathleen R. Delaney,1 Margery Chisholm, 2 Jeanne Clement, 3 and Elizabeth I. Merwin 4 Eighty-five program coordinators responded to a survey concerning Psychiatric Mental Health (PMH) graduate-nursing education. Twelve of these 85 program coordinators reported their programs had closed. Data from the remaining 73 indicated that the number of students entering PMH graduate programs is small. In the past 2 years, most programs have undergone some redesign. A significant curricular trend is the inclusion of pharmacology, physical a s s e s s m e n t , and pathophysiology. Another trend is the shift to a Nurse Practitioner (NP)-type curriculum. PMH curricula seem increasingly modeled on a primary mental health care model and training in a broad base of skills. Copyright © 1999 by W.B. Saunders Company
CCORDING TO A 1996 list compiled by the National League for Nursing (NLN), 86 accredited masters programs in Psychiatric-Mental Health (PMH) nursing currently prepare graduates for a Certified Specialist (CS) degree. The NLN also lists 30 accredited Psychiatric Nurse Practitioner (NP) programs. Seventeen schools appear on both the CS and NP program lists so that the actual number of accredited programs preparing PMH graduate nurses is 99. This article reports on the results of a recent survey of these 99 PMH programs. The purpose of the survey was to track changes in the focus of PMH graduate education, to determine the number of programs operating and the size of the graduating classes, and to obtain summary descriptions of recent curricular changes. The survey grew out of the Society for Education and Research in Psychiatric Mental Health Nursing (1997a) (SERPN) Advanced Practice Nursing Project. This large, advanced-practice survey focused on how the work force was educated at the dawn of the health care revolution. We questioned what changes had occurred in graduate education in the tumultuous intervening years. METHODS
Participants
The survey was mailed to 99 university/collegebased PMH graduate programs, to the addresses as
they appeared on the NLN accreditation lists. Each envelope was sent to the attention of the Coordinator of Psychiatric Nursing Graduate Education or the Coordinator of Nursing Graduate Education. Survey Instrument
The survey was a one-page form that posed six basic questions. First, participants were asked the title of the program. The next question dealt with the emphasis of the program. Several forced-choice options were provided, as well as room to fill in additional emphasis foci (Table 1). The third question asked what credentialing exams in nursing the graduates were prepared for, i.e. the CS or NP exam. Next, we inquired about the number of graduates from the program both in 1996 and in 1997. The final two questions were open-ended. One queried participants on any recent (within the past 2 years) curriculum revisions, such as a shift in emphasis or the addition of new course work. The final questions asked participants to explain if their
From the ~Rush College of Nursing, Chicago, IL; the 2Northeastern University, Boston, MA; the 3Ohio State University, Columbus, OH; and the ~University of Virginia, Charlottesville, VA. Address reprint requests to Kathleen Delaney, D.N.S.c., R.N., 2129 Sherman Street, Evanston, IL, 60201. Copyright © 1999 by W.B. Saunders Company 0883-9417/99/1302-0001510.00/0
Archives of Psychiatric Nursing, Vol.XIII,No. 2 (April), 1999: pp 67-73
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DELANEY ET AL. Table 1. Survey Choices of Program Emphasis Advanced psychiatric mental health nursing CS role (therapy courses plus systems/managed care foci) Primary mental health care (therapy courses plus physical assessment, pathophysiology, differential diagnosis) Community mental health Other (e.g., neuropsychiatdc, administration, liaison) Practitioner focus Psychiatric family nurse practitioner Community mental health nurse practitioner Psychiatric nurse practitioner Other (please specify)
program had recently closed or combined with another graduate program at their university. If the program had closed, we inquired if the PMH content had been shifted in any form to another program. The reverse side of the form had space for explanations of any multiple educational options offered, such as programs that combine a PMH-CS track with an adult or family NR Participants were also asked to explain if a PMH option was embedded in a generic NP program. Finally, we asked for elaboration on any extension/off-campus sites that operate at the university. If available, participants were asked to include, with their returned survey, any printed material available on the program, such as a brochure or sample program of study. The bottom of the form had a space for any additional comments. Procedure
The survey was piloted with 10 PMH graduate program in the Midwest. In its initial form, the survey was much more detailed, asking for specifics on curriculum content and clinical practicums. The pilot participants commented, almost unanimously, that the survey was too lengthy and that it was difficult to equate specific content with several curriculum categories listed on the tool. The pilot group also noted that they recently responded to an extensive PMH curriculum survey circulated by another study group (American Nurses Association, 1996). Based on this feedback, the survey was abbreviated to the six essential questions elaborated above and piloted with the 30 schools in SERPN's Midwest Region. Minor word changes were made based on the feedback from these participants. Finally, the survey was sent out to all 99 graduate
programs in April 1997, along with a cover letter and a stamped return envelope. A month later a new survey, cover letter, and stamped envelope was sent to the schools that did not respond to the first request. Finally, 2 months later, phone calls were made to several of the nonresponding schools in an effort to locate specific contact persons or to ascertain if the PMH program had closed. RESULTS
Eighty-five of the 99 schools replied to the survey resulting in an 85.8% return rate. Of the 85 respondents, 12 reported that their program had closed. Thus this report is based on the 73 responding schools whose programs remain open. Of the 73 programs, approximately one quarter (24%) has maintained a somewhat traditional title of Masters in Psychiatric Mental Health Nursing. Another 20% have switched to a title centered on the term Advanced Practice Nurse. Ten schools have added the term Psychiatric Nurse Practitioner to their title, whereas another 10 have a title branching off the APN name, e.g., Advanced Practice Nurse: Psychiatric Mental Health Nursing. Finally, there is a group of schools that titles their program under a specialty name such as Family Mental Health, Community Mental Health, Psychiatric Nursing Administration, or Liaison Nursing. The diversity of titles reflects a diversity of emphasis currently operating in the 73 programs (Table 2). Only 13 programs checked the foci of the program as solely CS-role preparation, and of these, 4 indicated that they recently added physical assessment, pathophysiology, and pharmacolgy. Two of these 13 schools are considering an NP/CS option, and three are considering major curriculum change. There were 10 schools that considered their focus both the CS-role preparation and community
Table 2. Emphasis of 72* PMH Graduate Programs Foci of Programs CS role preparation CS role preparation/community mental health focus Community mental health focus Primary mental health Dual degree option/dual foci Practitioner focus *One school left this question blank.
Number of Programs 13 10 2 13 16 18
TRENDS IN PMH GRADUATE EDUCATION
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mental health, and two additional schools checked just the community mental health emphasis. Several of these schools have subspecialty options under the CS/community mental health role umbrella, such as a concentration in child mental health, transcultural nursing, addictions, administration, geriatrics, or the seriously and persistently mentally ill. An additional note: 5 of these 12 schools have also recently added pharmacology, pathophysiology, and health assessment. Thirteen program coordinators marked their emphasis as Primary Mental Health Care. Three of these programs are considering offering a CS/NP option in the future. Sixteen schools are now offering a dual degree option where the CS degree can be paired with a NP degree. In these programs, the student completes the CS curriculum and then adds the needed NP courses as either a dual degree or postmasters option. Finally, 18 schools offer curricula where CS and NP courses have been integrated so that graduates are credentialed NP at either the state level or through an adult NP exam offered by the American Nurses Credentialing Center (ANCC). Adding these 18 blended programs to the 16 schools that offer a dual-degree option, approximately 46% of PMH graduate schools offer some type of NP education.
Even with this move to NP education, on graduation, 98% of students still sit for the CS exam. Although students completing the dual degree option (16 programs) are eligible to sit for an ANCC NP exam, respondents indicated that their graduates were also prepared to sit for the PMH-CS exam. The University of Pittsburgh's program is unique in that graduates only sit for the Adult NP exam although they are titled Psychiatric Primary Care Nurse Practitioners (Dyer, Harmnill, ReganKubinski, Urick, & Kobert, 1997). The graduates of the 18 schools who have created NP programs through blending NP and CS content are certified through the CS exam but obtain the title of NP in various ways. Six of the 18 schools with blended programs are in New York State where graduates of accredited Psychiatric Nurse Practitioner programs are titled NP by the state. Also, several of this group of 18 are in states where all Advanced Practice Nurses are tiled Advanced Registered Nurse Practitioner (ARNP). Thus, the students take the title of Nurse Practitioner by virtue of state regulations. Several of the respondents in this group of 18 indicated that they are hoping a PMH-NP exam will soon be developed. The number of students enrolled in PMH education is small. As indicated in Figure 1, in 1997, 42
32
35
30 o 25 20 q==
o 15
10 E 5 = 0
4
Z
(0-3)
(4-7)
(8-11)
(12-1 5)
(16 plus)
Number of students graduating Fig 1.
Students graduating from PMH master's programs in 1996 ([~) and 1997 (11).
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schools reported that less than eight students graduated from their program. There are 17 programs in a midrange of 8 to 11 students and only 6 large programs with greater than 12 graduates in a calendar year. These ranges are similar for 1996, although several programs may have slightly increased, whereas several slightly dropped numbers. In both years, at least five schools had zero graduates because they were undergoing major curriculum changes or had reopened the program after closing for a year. There were four respondents who did not include enrollment figures. The most varied responses occurred with the question concerning recent changes in the program curriculum. Of the 73 program directors that returned surveys, only 7 indicated that there were no recent curriculum changes, 2 respondents left it blank. Thus, 64 programs reported some type of curriculum change in the past 2 years. The most common change (noted by 22 schools) was the addition of either part or the entire panel of Primary Care Foundation Courses (Pharmacology, Physiology, and Physical Assessment). Another change noted (five schools) was the CS program being folded into the NP curriculum. Seven additional schools reported that a greater integration of NP and CS curricula had occurred, where core courses were developed for the 2 groups, but each program remained open. As reported, there is a trend toward branching where the students complete a CS and then have an option for an NP as a postmasters or dual degree. Five schools reported that significant curriculum change occurred because their school had switched from a quarter to semester system, and the director took this as an opportunity to combine courses and integrate the NP and CS tracks. Six schools are currently considering how to reorganize their curricula. Five programs were closed for a year during reorganization; three programs have just reopened and will graduate a class under the new curriculum in a year or two. Of these eight newly designed programs, four have created integrated NP curricula; one has added a dual certification option. We also asked about distance learning programs. Off-site classes are offered at five programs; two additional programs are starting a distance-learning program this year. Thus, this relatively new technology is only slowly entering the PMH educational arena.
DELANEY ET AL.
Approximately 25 respondents added additional comments to the questionnaire. The comments are quite varied but several themes could be abstracted. Several respondents voiced concern about the dwindling number of students entering their program. Three spoke of the tension between the various programs in the university. Three commented that student numbers were so small that they were moving to close or to offer courses every other year. Only three participants went against a trend of concern, commenting that their programs were going well and attracting students. The NP versus CS debate was also addressed. Two participants raised the issue of NP versus CS titling, stating that there needs to be closure on the question. Two commented that the problems of state regulations made the entire NP versus CS question a problem. Two respondents added that their program does not believe physical assessments are compatible with the CS or NP role. Finally three commented that students were seeking an NP option and that some type of NP exam in psychiatry needed to be developed.
DISCUSSION
Eighty-five PMH program coordinators responded to a survey concerning trends in graduate education. Results indicate, with few exceptions, the numbers of students entering graduate programs in Psychiatric Mental Health Nursing (PMH) are small. The decline in PMH graduate enrollment stands in contrast to the sharp increases in the students entering NP programs throughout the country (AACN, 1995). Beyond the current appeal of NP education, a possible contributing factor to low enrollment may be the shrinking base of CNS jobs in some regions, and in turn, attracting students to the specialty (Malone, 1993). Although the spectrum of Primary Mental Health Care suggests exciting possibilities for Advanced Practice Psychiatric Nurses, (Krauss, 1993; Haber & Billings, 1995), the restructuring of mental health services is ongoing and the integration of Advanced Practice Psychiatric Nurses into managed care environments remains in an infancy stage (Mitchell & Reaghard, 1996). In some respects, the specialty seems to be working its way through a professional transition, and its effects may have reverberated into the educational arena.
TRENDS IN PMH GRADUATE EDUCATION
On the other hand, the surveys indicate PMH program coordinators have been very active in redesigning programs to address current directions in mental health treatment. A significant curricular trend is the inclusion of pharmacology, physical assessment, and pathophysiology courses. This emphasis is consistent with the neurobiolgical view of mental illness, the direction of providing mental health treatment within a primary care system, and the curriculum recommendations of both SERPN and the ANA task on Psychopharmacology (ANA, 1994; SERPN, 1996). The shift to NP education is occurring on several fronts; programs offering a Psychiatric NP degree in which graduates axe credentialed NP at the state level, dual-focus degrees whose graduates complete two programs (NP/CS), and curricula creating blended and new models for Psychiatric Nurse Practitioners. The new, innovative NP curriculums are quite varied. The University of Pittsburgh has completely integrated the essential PMH content with primary care skills. Their model is unique in that all the faculty are dual-prepared as both Psychiatric CSs and NPs, and their graduates sit for the Adult NP exam (Dyer et al, 1997). The University of Tennessee Model creates a Psychiatric Family Nurse Practitioner; the primary care skills are combined with an emphasis on family, connecting all levels of care in a comprehensive manner (Scandrett-Hibdon, Wood, Cunningham, & Kolbach, 1995). Another variation of a Psychiatric Nurse Practitioner track has been created at University of California at Los Angeles. Here students in any adult nurse practitioner course may elect to enter the neuropsychiatric nurse practitioner subspecialty in their second year. In this subspecialty year, students receive both didactic and clinical experience in cognitive dysfunction, affective disorders, and addictive dysfunctions (Gordon, 1996). The blended programs that prepare graduates for NP credentialing at the state level vary in structure. One model described in the literature originates from Strong Memorial Hospital in collaboration with University of Rochester (Cornwell & Chiverton, 1997). In this model, the student first completes a PMH masters leading to a CS and then takes the required number of courses for the state NP certification. Of interest in this model is the careful consideration of curriculum content to assure sufficient preparation of graduates for the roles they would assume. Finally, there is an NP
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model originating at the University of Washington, the Psychosocial Nurse Practitioner Expanded Role. Here the student takes additional assessment and conunon-health concern courses so that the student is prepared to manage clients' psychosocial care (including medications) as well as coordinate the total health care and manage common-health concerns (O'Conner, Thomas, Olivares, Brandt, & Boutain, 1997). The 18 dual-degree programs vary from these curricula because, in these options, the student completes the PMH-CS program, then the graduate takes all or a major portion of an adult NP track. There are many variations in how these programs add credits and design clinical practiciums. Several respondents included credit hours of these dualdegree programs, and the average assignment of credits is a 38 semester hours of a CNS program with the addition of 12 to 14 NP credits to create a 50-credit CS/NP option. This rather long program of study is in line with recommendations for preparing graduates with broad based skills (Cronenwett, 1995) yet presents obvious pragmatic considerations. Occurring alongside dual-degree options is another trend towards greater integration of NP and CS core courses. Two respondents commented that they were moving towards the AACN recommendations for integrating master's programs. Other programs described their core curriculum designed for the first year of both CNS and NP programs. This trend may be a reflection of the view of diminishing differences between the two roles and a response to administration demands for merged curricula to conserve educational resources (Gaines, 1994). In addition to an increasing emphasis on primarycare skills, there seems to be a trend toward creating specialty foci, such as community, family, or addictions tracks. Program material sent from one Midwestern school indicated that beyond the core PMH curriculum, the student has the option of one of six specialty foci. Another program has adapted a life span approach and within that framework offers several subspecialty areas, such as the family or persons with serious and persistent mental illness. Along with the excitement of change, participants voiced themes of concern over the dwindling number of students, competition with other programs in the university, and the need to settle on a
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DELANEY ET AL.
tide and focus of PMH graduate education. It must be noted that particular program coordinators offered positive comments about enrollment and the employment demands for their graduates. One respondent commented that in her university, the PMH program has the largest number of applicants of any single nursing graduate program. IMPLICATIONS
PMH masters programs operate on a diversity of models. This diversification seems an appropriate response to specialty populations within a particular region and the diversity of state credentialing laws (Pearson, 1997). The response is also in line with the move toward blended curricula, the neurobiological focus, and primary mental health care roles (AACN, 1994; Talley & Caverly, 1994). The freedom to create has resulted in fascinating variations. However, we may be coming to a point where diversity must be balanced with some degree of uniformity. At the very least there should be consensus on essential Psychiatric Mental Health nursing content. Such curriculum recommendations exist (SERPN, 1996) yet a recent survey found most programs not incorporating the recommendations (ANA, 1996). The number of PMH program directors is relatively small. It may be a good time to form a communication network. Program directors might come together with some sense of uniformity on the knowledge base for the PMH generalist and subspecialty/population-based practice. However, we live in a practical world. Consolidations, integrations, and branching of programs are bound to increase. Many programs are poised to train a hybrid of the NP and CS nurse, and that blended education might be the appropriate amalgam of the psychosocial tradition and the biological perspective (Moller& Haber, 1996). It also seems suitable for what is being forecasted in a managedcare environment and appropriate for the needs of the undeserved populations that are of concern to psychiatric nurses. The trend towards primary mental health care and the creation of a broad base of PMH education puts another angle on the debate about CS versus NP titling. The pro and con arguments about combining the roles have appeared in any number of articles (Caverly, 1995; Elder & Bullough, 1990; Lego, 1995; Naylor & Brooten, 1993; Page & Arena, 1994; Williams & Valdivieso, 1994). How-
ever, as the debate goes on, market forces and curriculum trends seem to be moving education towards a Primary Mental Health Care model that blends the two roles. Primary mental health care has been characterized as services that begin with a comprehensive assessment of physical, biological, and psychosocial concerns and then assume responsibility for the client and family's mental-health needs over time as well as coordinating services with other systems (SERPN, 1997b). Considering the base of skills this role demands, the move to a broad-based education seems correct. As emerging primary care roles and the accompanying educational models to prepare the workforce for these roles evolve, we as a professional subspecialty may not so much mandate a titling change as move toward it on the heels of the logic of market forces, population needs, state regulations, and the science of treatment.
REFERENCES American Association of Colleges of Nursing. (1994). Annual report: Unifying the curricula for advanced practice.
Washington, DC: Author. American Association of Colleges of Nursing. (1995). 19941995 Special report on Master's and Post-Masters nurse practitioner programs; faculty practice, clinical practice, faculty age profiles, undergraduate curriculum expansion in baccalaureate & graduate programs in nursing. Washington,DC: Author. AmericanNursesAssociation,(1994).Psychiatric Mental Health Nursing Pharmacology Project. Washington,DC: Ameri-
can Nurses Publishing. American Nurses Association. (1996). Report on curriculum survey for nurse practitioner and mental health nurses.
Unpublished manuscript. Caverly, S. (1995). Clinical Nurse Specialist or Nurse Practitioner: An issue of semantics, not true differences. Journal of the American Psychiatric Nurses Association,
1, 61, 63-65. Cornwell, C., & Chiverton, R (1997). The psychiatric advanced practice nurse with prescriptive authority:Role development, practice issues, and outcomes measurement. Archives of Psychiatric Nursing, 11, 57-65. Cronenwett, L.R. (1995). Molding the future of Advanced Practice Nursing. Nursing Outlook, 43, 112-118. Dyer, J.G., Hammill, K., Regan-Kubinski, M.J., Yurick, A., & Kobert, S. (1997). The Psychiatric-PrimaryCare Nurse Practitioner: A futuristic model for Advanced Practice Psychiatric-Mental Health Nursing. Archives of Psychiatric Nursing, I1, 2-12. Elder, R.G., & Bullough, B. (1990). Nurse practitioners and clinical nurse specialists:Are the roles merging?Clinical Nurse Specialist, 4, 78-84.
TRENDS IN PMH GRADUATE EDUCATION
Gaines, S.K. (1993). Curricular models in master's nursing education: Surviving the 90s and securing the future. Paper presented at a regional conference sponsored by Faculty Development for Graduate Nurse Educators project, Atlanta, GA. Gordon, J. (1996). The Neuropsych NP specialist. Nursing News: UCLA School of Nursing, Fall, (1). Haber, J., & Billings, C.V. (1995). Primary mental health care: A model for psychiatric-mental health nursing. Journal of the American Psychiatric Nurses Association, 1, 154163. Krauss, J.B. (1993). Health care reform: Essential mental health services. Washington, DC: American Nurses Publishing. Lego, S. (1995). A Psychiatric Nurse Practitioner is not a Clinical Nurse Specialist. Journal of the American Psychiatric Nurses Association, 1, 61-63. Malone, J.A. (1993). What's happening to clinical nurse specialists in psychiatric mental health nursing? Journal of Psychosocial Nursing, 3•(7), 37-39. Mitchell, A., & Reaghard, D.A. (1996). Managed care and psychiatric-mental health nursing services: Implications for practice. Issues in Mental Health Nursing, 17, 1-9. Moller, M.D., & Haber, J. (1996). Advanced practice psychiatric nursing: A rose by any other name. Online Journal of Issues in Nursing, 1(1), (August 1). Naylor, M.D., & Brooten, D. (1993). The roles and functions of clinical nurse specialists. Image: Journal of Nursing Scholarship, 25, 73-78. O'Connor, R., Thomas, M.D., Olivares, S., Brandt, E, & Boutain, D. (1997). Challenges for a new Psychosocial Nurse Practitioner Program. Paper presented at the
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annual national conference of Society for Education and Research in Psychiatric Nursing, Washington, DC. Page, N.E., & Arena, D.M. (1994). Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles. Image: Journal of Nursing Scholarship, 26, 315-318. Pearson, LJ. (1997). Annual update on how each state stands on legislative issues affecting Advanced Practice Nursing. Nurse Practitioner, 22, 18-86. Scandrett-Hibdon, S.L., Woods, M.H., Cunningham, P., & Kolbach, A. (1995). Psychiatric Family Nurse Practitioner: Addressing the role. Paper presented at annual national conference of Society for Education and Research in Psychiatric Nursing, Washington, DC. Society for Education and Research in Psychiatric-Mental Health Nursing. (1996). Educational Preparation for Psychiatric-Mental Health Nursing Practice. Pensacola, FL: Author. Society for Education and Research in Psychiatric Mental Health Nursing. (1997a). Primary mental health and advanced practice psychiatric nursing. Pensacola, FL: Author. Society for Education and Research in Psychiatric Mental Health Nursing. (1997b). Quality indicators for primary mental health care within managed care: A public health focus. Unpublished manuscript. Talley, S., & Caverly, S. (1994). Advanced-practice psychiatric nursing and health care reform. Hospital and Community Psychiatry, 45, 545-547. Williams, C.A., & Valdivieso, G.C. (1994). Advanced practice models: A comparison of clinical nurse specialist and nurse practitioner activities. Clinical Nurse Specialist, 8, 311-318.
CCORDING TO A 1996 list compiled by the National League for Nursing (NLN), 86 accredited masters programs in Psychiatric-Mental Health (PMH) nursing currently prepare graduates for a Certified Specialist (CS) degree. The NLN also lists 30 accredited Psychiatric Nurse Practitioner (NP) programs. Seventeen schools appear on both the CS and NP program lists so that the actual number of accredited programs preparing PMH graduate nurses is 99. This article reports on the results of a recent survey of these 99 PMH programs. The purpose of the survey was to track changes in the focus of PMH graduate education, to determine the number of programs operating and the size of the graduating classes, and to obtain summary descriptions of recent curricular changes. The survey grew out of the Society for Education and Research in Psychiatric Mental Health Nursing (1997a) (SERPN) Advanced Practice Nursing Project. This large, advanced-practice survey focused on how the work force was educated at the dawn of the health care revolution. We questioned what changes had occurred in graduate education in the tumultuous intervening years. METHODS
Participants
The survey was mailed to 99 university/collegebased PMH graduate programs, to the addresses as
they appeared on the NLN accreditation lists. Each envelope was sent to the attention of the Coordinator of Psychiatric Nursing Graduate Education or the Coordinator of Nursing Graduate Education. Survey Instrument
The survey was a one-page form that posed six basic questions. First, participants were asked the title of the program. The next question dealt with the emphasis of the program. Several forced-choice options were provided, as well as room to fill in additional emphasis foci (Table 1). The third question asked what credentialing exams in nursing the graduates were prepared for, i.e. the CS or NP exam. Next, we inquired about the number of graduates from the program both in 1996 and in 1997. The final two questions were open-ended. One queried participants on any recent (within the past 2 years) curriculum revisions, such as a shift in emphasis or the addition of new course work. The final questions asked participants to explain if their
From the ~Rush College of Nursing, Chicago, IL; the 2Northeastern University, Boston, MA; the 3Ohio State University, Columbus, OH; and the ~University of Virginia, Charlottesville, VA. Address reprint requests to Kathleen Delaney, D.N.S.c., R.N., 2129 Sherman Street, Evanston, IL, 60201. Copyright © 1999 by W.B. Saunders Company 0883-9417/99/1302-0001510.00/0
Archives of Psychiatric Nursing, Vol.XIII,No. 2 (April), 1999: pp 67-73
67
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DELANEY ET AL. Table 1. Survey Choices of Program Emphasis Advanced psychiatric mental health nursing CS role (therapy courses plus systems/managed care foci) Primary mental health care (therapy courses plus physical assessment, pathophysiology, differential diagnosis) Community mental health Other (e.g., neuropsychiatdc, administration, liaison) Practitioner focus Psychiatric family nurse practitioner Community mental health nurse practitioner Psychiatric nurse practitioner Other (please specify)
program had recently closed or combined with another graduate program at their university. If the program had closed, we inquired if the PMH content had been shifted in any form to another program. The reverse side of the form had space for explanations of any multiple educational options offered, such as programs that combine a PMH-CS track with an adult or family NR Participants were also asked to explain if a PMH option was embedded in a generic NP program. Finally, we asked for elaboration on any extension/off-campus sites that operate at the university. If available, participants were asked to include, with their returned survey, any printed material available on the program, such as a brochure or sample program of study. The bottom of the form had a space for any additional comments. Procedure
The survey was piloted with 10 PMH graduate program in the Midwest. In its initial form, the survey was much more detailed, asking for specifics on curriculum content and clinical practicums. The pilot participants commented, almost unanimously, that the survey was too lengthy and that it was difficult to equate specific content with several curriculum categories listed on the tool. The pilot group also noted that they recently responded to an extensive PMH curriculum survey circulated by another study group (American Nurses Association, 1996). Based on this feedback, the survey was abbreviated to the six essential questions elaborated above and piloted with the 30 schools in SERPN's Midwest Region. Minor word changes were made based on the feedback from these participants. Finally, the survey was sent out to all 99 graduate
programs in April 1997, along with a cover letter and a stamped return envelope. A month later a new survey, cover letter, and stamped envelope was sent to the schools that did not respond to the first request. Finally, 2 months later, phone calls were made to several of the nonresponding schools in an effort to locate specific contact persons or to ascertain if the PMH program had closed. RESULTS
Eighty-five of the 99 schools replied to the survey resulting in an 85.8% return rate. Of the 85 respondents, 12 reported that their program had closed. Thus this report is based on the 73 responding schools whose programs remain open. Of the 73 programs, approximately one quarter (24%) has maintained a somewhat traditional title of Masters in Psychiatric Mental Health Nursing. Another 20% have switched to a title centered on the term Advanced Practice Nurse. Ten schools have added the term Psychiatric Nurse Practitioner to their title, whereas another 10 have a title branching off the APN name, e.g., Advanced Practice Nurse: Psychiatric Mental Health Nursing. Finally, there is a group of schools that titles their program under a specialty name such as Family Mental Health, Community Mental Health, Psychiatric Nursing Administration, or Liaison Nursing. The diversity of titles reflects a diversity of emphasis currently operating in the 73 programs (Table 2). Only 13 programs checked the foci of the program as solely CS-role preparation, and of these, 4 indicated that they recently added physical assessment, pathophysiology, and pharmacolgy. Two of these 13 schools are considering an NP/CS option, and three are considering major curriculum change. There were 10 schools that considered their focus both the CS-role preparation and community
Table 2. Emphasis of 72* PMH Graduate Programs Foci of Programs CS role preparation CS role preparation/community mental health focus Community mental health focus Primary mental health Dual degree option/dual foci Practitioner focus *One school left this question blank.
Number of Programs 13 10 2 13 16 18
TRENDS IN PMH GRADUATE EDUCATION
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mental health, and two additional schools checked just the community mental health emphasis. Several of these schools have subspecialty options under the CS/community mental health role umbrella, such as a concentration in child mental health, transcultural nursing, addictions, administration, geriatrics, or the seriously and persistently mentally ill. An additional note: 5 of these 12 schools have also recently added pharmacology, pathophysiology, and health assessment. Thirteen program coordinators marked their emphasis as Primary Mental Health Care. Three of these programs are considering offering a CS/NP option in the future. Sixteen schools are now offering a dual degree option where the CS degree can be paired with a NP degree. In these programs, the student completes the CS curriculum and then adds the needed NP courses as either a dual degree or postmasters option. Finally, 18 schools offer curricula where CS and NP courses have been integrated so that graduates are credentialed NP at either the state level or through an adult NP exam offered by the American Nurses Credentialing Center (ANCC). Adding these 18 blended programs to the 16 schools that offer a dual-degree option, approximately 46% of PMH graduate schools offer some type of NP education.
Even with this move to NP education, on graduation, 98% of students still sit for the CS exam. Although students completing the dual degree option (16 programs) are eligible to sit for an ANCC NP exam, respondents indicated that their graduates were also prepared to sit for the PMH-CS exam. The University of Pittsburgh's program is unique in that graduates only sit for the Adult NP exam although they are titled Psychiatric Primary Care Nurse Practitioners (Dyer, Harmnill, ReganKubinski, Urick, & Kobert, 1997). The graduates of the 18 schools who have created NP programs through blending NP and CS content are certified through the CS exam but obtain the title of NP in various ways. Six of the 18 schools with blended programs are in New York State where graduates of accredited Psychiatric Nurse Practitioner programs are titled NP by the state. Also, several of this group of 18 are in states where all Advanced Practice Nurses are tiled Advanced Registered Nurse Practitioner (ARNP). Thus, the students take the title of Nurse Practitioner by virtue of state regulations. Several of the respondents in this group of 18 indicated that they are hoping a PMH-NP exam will soon be developed. The number of students enrolled in PMH education is small. As indicated in Figure 1, in 1997, 42
32
35
30 o 25 20 q==
o 15
10 E 5 = 0
4
Z
(0-3)
(4-7)
(8-11)
(12-1 5)
(16 plus)
Number of students graduating Fig 1.
Students graduating from PMH master's programs in 1996 ([~) and 1997 (11).
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schools reported that less than eight students graduated from their program. There are 17 programs in a midrange of 8 to 11 students and only 6 large programs with greater than 12 graduates in a calendar year. These ranges are similar for 1996, although several programs may have slightly increased, whereas several slightly dropped numbers. In both years, at least five schools had zero graduates because they were undergoing major curriculum changes or had reopened the program after closing for a year. There were four respondents who did not include enrollment figures. The most varied responses occurred with the question concerning recent changes in the program curriculum. Of the 73 program directors that returned surveys, only 7 indicated that there were no recent curriculum changes, 2 respondents left it blank. Thus, 64 programs reported some type of curriculum change in the past 2 years. The most common change (noted by 22 schools) was the addition of either part or the entire panel of Primary Care Foundation Courses (Pharmacology, Physiology, and Physical Assessment). Another change noted (five schools) was the CS program being folded into the NP curriculum. Seven additional schools reported that a greater integration of NP and CS curricula had occurred, where core courses were developed for the 2 groups, but each program remained open. As reported, there is a trend toward branching where the students complete a CS and then have an option for an NP as a postmasters or dual degree. Five schools reported that significant curriculum change occurred because their school had switched from a quarter to semester system, and the director took this as an opportunity to combine courses and integrate the NP and CS tracks. Six schools are currently considering how to reorganize their curricula. Five programs were closed for a year during reorganization; three programs have just reopened and will graduate a class under the new curriculum in a year or two. Of these eight newly designed programs, four have created integrated NP curricula; one has added a dual certification option. We also asked about distance learning programs. Off-site classes are offered at five programs; two additional programs are starting a distance-learning program this year. Thus, this relatively new technology is only slowly entering the PMH educational arena.
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Approximately 25 respondents added additional comments to the questionnaire. The comments are quite varied but several themes could be abstracted. Several respondents voiced concern about the dwindling number of students entering their program. Three spoke of the tension between the various programs in the university. Three commented that student numbers were so small that they were moving to close or to offer courses every other year. Only three participants went against a trend of concern, commenting that their programs were going well and attracting students. The NP versus CS debate was also addressed. Two participants raised the issue of NP versus CS titling, stating that there needs to be closure on the question. Two commented that the problems of state regulations made the entire NP versus CS question a problem. Two respondents added that their program does not believe physical assessments are compatible with the CS or NP role. Finally three commented that students were seeking an NP option and that some type of NP exam in psychiatry needed to be developed.
DISCUSSION
Eighty-five PMH program coordinators responded to a survey concerning trends in graduate education. Results indicate, with few exceptions, the numbers of students entering graduate programs in Psychiatric Mental Health Nursing (PMH) are small. The decline in PMH graduate enrollment stands in contrast to the sharp increases in the students entering NP programs throughout the country (AACN, 1995). Beyond the current appeal of NP education, a possible contributing factor to low enrollment may be the shrinking base of CNS jobs in some regions, and in turn, attracting students to the specialty (Malone, 1993). Although the spectrum of Primary Mental Health Care suggests exciting possibilities for Advanced Practice Psychiatric Nurses, (Krauss, 1993; Haber & Billings, 1995), the restructuring of mental health services is ongoing and the integration of Advanced Practice Psychiatric Nurses into managed care environments remains in an infancy stage (Mitchell & Reaghard, 1996). In some respects, the specialty seems to be working its way through a professional transition, and its effects may have reverberated into the educational arena.
TRENDS IN PMH GRADUATE EDUCATION
On the other hand, the surveys indicate PMH program coordinators have been very active in redesigning programs to address current directions in mental health treatment. A significant curricular trend is the inclusion of pharmacology, physical assessment, and pathophysiology courses. This emphasis is consistent with the neurobiolgical view of mental illness, the direction of providing mental health treatment within a primary care system, and the curriculum recommendations of both SERPN and the ANA task on Psychopharmacology (ANA, 1994; SERPN, 1996). The shift to NP education is occurring on several fronts; programs offering a Psychiatric NP degree in which graduates axe credentialed NP at the state level, dual-focus degrees whose graduates complete two programs (NP/CS), and curricula creating blended and new models for Psychiatric Nurse Practitioners. The new, innovative NP curriculums are quite varied. The University of Pittsburgh has completely integrated the essential PMH content with primary care skills. Their model is unique in that all the faculty are dual-prepared as both Psychiatric CSs and NPs, and their graduates sit for the Adult NP exam (Dyer et al, 1997). The University of Tennessee Model creates a Psychiatric Family Nurse Practitioner; the primary care skills are combined with an emphasis on family, connecting all levels of care in a comprehensive manner (Scandrett-Hibdon, Wood, Cunningham, & Kolbach, 1995). Another variation of a Psychiatric Nurse Practitioner track has been created at University of California at Los Angeles. Here students in any adult nurse practitioner course may elect to enter the neuropsychiatric nurse practitioner subspecialty in their second year. In this subspecialty year, students receive both didactic and clinical experience in cognitive dysfunction, affective disorders, and addictive dysfunctions (Gordon, 1996). The blended programs that prepare graduates for NP credentialing at the state level vary in structure. One model described in the literature originates from Strong Memorial Hospital in collaboration with University of Rochester (Cornwell & Chiverton, 1997). In this model, the student first completes a PMH masters leading to a CS and then takes the required number of courses for the state NP certification. Of interest in this model is the careful consideration of curriculum content to assure sufficient preparation of graduates for the roles they would assume. Finally, there is an NP
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model originating at the University of Washington, the Psychosocial Nurse Practitioner Expanded Role. Here the student takes additional assessment and conunon-health concern courses so that the student is prepared to manage clients' psychosocial care (including medications) as well as coordinate the total health care and manage common-health concerns (O'Conner, Thomas, Olivares, Brandt, & Boutain, 1997). The 18 dual-degree programs vary from these curricula because, in these options, the student completes the PMH-CS program, then the graduate takes all or a major portion of an adult NP track. There are many variations in how these programs add credits and design clinical practiciums. Several respondents included credit hours of these dualdegree programs, and the average assignment of credits is a 38 semester hours of a CNS program with the addition of 12 to 14 NP credits to create a 50-credit CS/NP option. This rather long program of study is in line with recommendations for preparing graduates with broad based skills (Cronenwett, 1995) yet presents obvious pragmatic considerations. Occurring alongside dual-degree options is another trend towards greater integration of NP and CS core courses. Two respondents commented that they were moving towards the AACN recommendations for integrating master's programs. Other programs described their core curriculum designed for the first year of both CNS and NP programs. This trend may be a reflection of the view of diminishing differences between the two roles and a response to administration demands for merged curricula to conserve educational resources (Gaines, 1994). In addition to an increasing emphasis on primarycare skills, there seems to be a trend toward creating specialty foci, such as community, family, or addictions tracks. Program material sent from one Midwestern school indicated that beyond the core PMH curriculum, the student has the option of one of six specialty foci. Another program has adapted a life span approach and within that framework offers several subspecialty areas, such as the family or persons with serious and persistent mental illness. Along with the excitement of change, participants voiced themes of concern over the dwindling number of students, competition with other programs in the university, and the need to settle on a
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tide and focus of PMH graduate education. It must be noted that particular program coordinators offered positive comments about enrollment and the employment demands for their graduates. One respondent commented that in her university, the PMH program has the largest number of applicants of any single nursing graduate program. IMPLICATIONS
PMH masters programs operate on a diversity of models. This diversification seems an appropriate response to specialty populations within a particular region and the diversity of state credentialing laws (Pearson, 1997). The response is also in line with the move toward blended curricula, the neurobiological focus, and primary mental health care roles (AACN, 1994; Talley & Caverly, 1994). The freedom to create has resulted in fascinating variations. However, we may be coming to a point where diversity must be balanced with some degree of uniformity. At the very least there should be consensus on essential Psychiatric Mental Health nursing content. Such curriculum recommendations exist (SERPN, 1996) yet a recent survey found most programs not incorporating the recommendations (ANA, 1996). The number of PMH program directors is relatively small. It may be a good time to form a communication network. Program directors might come together with some sense of uniformity on the knowledge base for the PMH generalist and subspecialty/population-based practice. However, we live in a practical world. Consolidations, integrations, and branching of programs are bound to increase. Many programs are poised to train a hybrid of the NP and CS nurse, and that blended education might be the appropriate amalgam of the psychosocial tradition and the biological perspective (Moller& Haber, 1996). It also seems suitable for what is being forecasted in a managedcare environment and appropriate for the needs of the undeserved populations that are of concern to psychiatric nurses. The trend towards primary mental health care and the creation of a broad base of PMH education puts another angle on the debate about CS versus NP titling. The pro and con arguments about combining the roles have appeared in any number of articles (Caverly, 1995; Elder & Bullough, 1990; Lego, 1995; Naylor & Brooten, 1993; Page & Arena, 1994; Williams & Valdivieso, 1994). How-
ever, as the debate goes on, market forces and curriculum trends seem to be moving education towards a Primary Mental Health Care model that blends the two roles. Primary mental health care has been characterized as services that begin with a comprehensive assessment of physical, biological, and psychosocial concerns and then assume responsibility for the client and family's mental-health needs over time as well as coordinating services with other systems (SERPN, 1997b). Considering the base of skills this role demands, the move to a broad-based education seems correct. As emerging primary care roles and the accompanying educational models to prepare the workforce for these roles evolve, we as a professional subspecialty may not so much mandate a titling change as move toward it on the heels of the logic of market forces, population needs, state regulations, and the science of treatment.
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TRENDS IN PMH GRADUATE EDUCATION
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annual national conference of Society for Education and Research in Psychiatric Nursing, Washington, DC. Page, N.E., & Arena, D.M. (1994). Rethinking the merger of the clinical nurse specialist and the nurse practitioner roles. Image: Journal of Nursing Scholarship, 26, 315-318. Pearson, LJ. (1997). Annual update on how each state stands on legislative issues affecting Advanced Practice Nursing. Nurse Practitioner, 22, 18-86. Scandrett-Hibdon, S.L., Woods, M.H., Cunningham, P., & Kolbach, A. (1995). Psychiatric Family Nurse Practitioner: Addressing the role. Paper presented at annual national conference of Society for Education and Research in Psychiatric Nursing, Washington, DC. Society for Education and Research in Psychiatric-Mental Health Nursing. (1996). Educational Preparation for Psychiatric-Mental Health Nursing Practice. Pensacola, FL: Author. Society for Education and Research in Psychiatric Mental Health Nursing. (1997a). Primary mental health and advanced practice psychiatric nursing. Pensacola, FL: Author. Society for Education and Research in Psychiatric Mental Health Nursing. (1997b). Quality indicators for primary mental health care within managed care: A public health focus. Unpublished manuscript. Talley, S., & Caverly, S. (1994). Advanced-practice psychiatric nursing and health care reform. Hospital and Community Psychiatry, 45, 545-547. Williams, C.A., & Valdivieso, G.C. (1994). Advanced practice models: A comparison of clinical nurse specialist and nurse practitioner activities. Clinical Nurse Specialist, 8, 311-318.