There is considerable discussion around the United States among graduate program faculty about the "right way to go" for masters level education in psychiatric nursing. The debate centers around whether to educate masters students for the traditional clinical nurse specialist (CNS) role, a combined clinical specialist/nurse practitioner (CNS/NP) role, or a psychiatric nurse practitioner (PNP) role. This paper proposes that the most efficacious role both professionally and socially is the PNP.

The purpose of this paper is threefold: 1) to describe a PNP program and the PNP role; 2) to discuss the rationale underlying the necessity of the PNP role; and 3) to discuss the advantages and disadvantages of this role. In conclusion, implications about the usefulness of the PNP role in the era of health care reform are presented.

The following scenario illustrates the current "job scene" in psychiatric nursing.

A psychiatric nurse earned her masters degree in 1971 as a clinical specialist in psychiatric mental health nursing. She is educationally and clinically well-grounded in psychopathology, individual, group, family therapy, and crisis intervention. She is currently employed as a CNS in an inpatient unit of a large 300-bed psychiatric facility. Recently, several inpatient units at the facility were "restructured" since the average length of patients' stay decreased to seven days. The inpatient CNS position was eliminated. The CNS considered changing to an outpatient practice since she is certified by the American Nurses Association as an Adult Psychiatric Mental Health Clinical Specialist. She is reimbursed by some insurance companies, but not all and Medicare does not reimburse her. Seeing the "handwriting on the wall",she decided to pursue only outpatient work. What can she offer a potential employer to make her more marketable? Because of her bachelor's degree in nursing, she already has assessment skills. Could she expand/refine these skills to learn the management of common medical problems in addition to doing psychotherapy? She has one master's degree; should she get a second master's degree and in what area? Some master's-prepared psychiatric nurses are entering Family Nurse Practitioner (FNP) programs to get a master's degree in Adult Primary Care. Why? One master's prepared psychiatric CNS who pursued a second master's degree in Adult Primary Care reported:

"Over time as a psychiatric CNS, I have seen a need for providers to treat patients holistically. My internal medicine colleague suggested that to « of patients being treated in his office of general practice have anxiety or depression." (Raymond, 1996)

Psychiatric nursing leaders offered the following views about psychiatric CNSs seeking a second master's degree in Adult Primary Health Care. A precursor who advocated for the Psychiatric CNS/PNP role, Dr. Jane Martin (1985), psychotherapist and Dean of the School of Nursing at West Virginia University, Morgantown, West Virginia, is a proponent of holistic care. She was one of the first psychiatric nurses to receive a master's degree in psychiatric nursing and a master's degree in primary care. Ten years ago, Martin recommended a future direction in psychiatric nursing of an educational curriculum rich in psychiatric mental health nursing content and advanced clinical nursing content. She suggested the addition of the primary care nurse practitioner's skills of advanced physical assessment, diagnosis, and management of chronic and episodic illnesses to the traditional psychiatric mental health nursing content. (Martin 1985, p. 52) A second psychiatric nurse educator stated: "My feeling is that only some Psych CNSs should also be PNPs - I don't believe it's necessary for all nurse psychotherapists to do physical exams or diagnostic tests. Some may even be opposed to prescribing psychopharmatherapeutic drugs. Others may feel that providing physical exams detracts from the psychotherapeutic role." (Hardin, 1996) A third nursing leader related that it would be useful to have a psychiatric nurse complete a physical assessment particularly with the chronically mentally ill. These three excerpts point to the need for integration of primary care with psychiatric nursing care.

Description of the Psychiatric Nurse Practitioner

The psychiatric NP, an advanced practice nurse, offers a proficiency in the art and science of short-term psychotherapy while having the additional advanced physical assessment skills. The psych NP described in this paper is the psychiatric primary care nurse practitioner at the University of Pittsburgh, Pittsburgh, PA. The Psychiatric Primary Care Nurse Practitioner (PPCNP) Program at the University of Pittsburgh School of Nursing prepares principal providers of holistic (medical and psychosocial) adult primary health care who treat psychiatric clients in a variety of settings. PPCNP students begin their plan of study in core courses on physical diagnosis, health promotion, pharmacology, pathophysiology, and management of acute, episodic, and chronic health problems.

Program content directly builds on these core concepts to provide students with the advanced practice skills to effectively manage both the common medical and complex psychobiological problems of persons with psychiatric disorders. Practicums provide opportunities for intensive and varied clinical experiences. The program is designed to qualify the student for credentialing by the state of Pennsylvania as a certified registered nurse practitioner, and certification by the American Nurses' Association as an adult nurse practitioner. (Unpublished brochure, University of Pittsburgh School of Nursing)

The sequence of courses is planned to provide the best opportunity for a logical building of the clinical decision-making skill necessary to function as a PPCNP. Specifically, health promotion, pathophysiology, pharmacology, and physical diagnosis are seen as foundational to the Psych NP program. Building on this foundation, the student generates a knowledge base of adult physical diagnosis and management of acute and chronic primary health care needs/problems. Neurobiology and psychopharmacology serve as a transition between general primary health care and specialized psychiatric nursing skills. Along with the nursing focus on full care provision ranging from mental health promotion to illness rehabilitation, the Psych NP role also involves interventions which encompass psychobiologic diagnosis and treatment. In addition, emphasis is placed on psychoeducation for these patients and their families to promote mental health and prevent subsequent mental disorders. Clinical experiences are designed so that students provide comprehensive management to psychiatric clients, including both physical and psychiatric care. Culminating clinical management practicums provide students with the opportunity to synthesize and integrate concepts from primary health care with their psychiatric knowledge base. (Unpublished brochure, University of Pittsburgh School of Nursing)

The PPCNP can work with psychiatric patients in a variety of settings such as ambulatory care clinics, psychiatric outpatient clinics, inpatient units, and private group practices. Because the PPCNP is certified by the Commonwealth of Pennsylvania Department of State, Bureau of Professional and Occupational Affairs, he/she can receive Medicare reimbursement as well as various other private insurance reimbursement. The product or commodity offered is primary care plus psychiatric care to mental health clients.

In 1983, the University of Pittsburgh School of Nursing received a Department of Health and Human Services training grant to integrate physical assessment skills and physical diagnosis into the psychiatric CNS curriculum. Students enrolled in the master's program in psychiatric nursing took physical assessment, physical diagnoses, and medical management courses and agreed to work in areas that had large numbers of chronically mentally ill patients. Students funded by the NIMH grant received full tuition and a stipend. Psychiatric nursing faculty worked with primary care faculty but courses were offered separately. Ten students graduated from the program.

Today several schools of nursing offer a hybrid of combinations of psychiatric nursing and nurse practitioner programs. The University of Virginia School of Nursing offers a masters degree in psychiatric mental health nursing with two options: the clinical nurse specialist option and the family nurse practitioner option. The University of Tennessee at Memphis has a Psychiatric Family Nurse Practitioner. The University of California at San Francisco offers a Master of Science that combines mental health with primary care components for service to vulnerable populations such as the severely mentally ill who are exposed to concomitant medical problems because of their lifestyle risk factors, and fragmentation of care. Vanderbilt University School of Nursing developed a Behavioral Health Nurse Practitioner (BHNP) with a similar focus of integrating primary care with mental health care in the community so the new BHNP can function in traditional psychiatric settings as well as primary care clinics, long-term centers or schools. The University of Southern Florida School of Nursing offers a psychiatric nurse practitioner program. The Society on Education & Research In Psychiatric Nursing (SERPN) Conference has addressed the issue of psychiatric nurse practitioner at its November 1995 National meeting in which several graduate programs presented their version of a psychiatric nurse practitioner. The merging of primary care and psychiatric care is an innovative strategy.

Rationale for the Psychiatric

Economics have dramatically changed health care, transforming a "social good" focus to a "commodity" sense orientation (Romoff, 1996). The health care industry is mimicking what other corporate industries such as the auto and steel industries went through several years ago, i.e. considerable downsizing, restructuring and profit/cost driven. Restructuring in health care produces a concomitant need to develop new practice roles and health delivery systems which also are driven by cost effectiveness and access to care. Psychiatric care, an integral component of health care, is part of the restructuring, thus affecting psychiatric mental health nurses.

Commercialization of psychiatric care is underway. Psychiatric inpatient admissions have decreased, admissions to general hospitals have decreased, while outpatient admissions are increasing. Academic centers are purchasing smaller hospitals as affiliates; satellite clinics and networks of services are being established. Physicians in solo practice are merging into group practices. New health care professional roles must be restructured and "cross trained" to maintain competitiveness by offering flexible, cost-saving effective care. This is the background environment in which the PPCNP is competing for a piece of the managed care dollar. The PPCNP provides a "Commodity or product" of quality psychiatric care combined with primary care emphasizing the psychotherapeutic skills. In her editorial in Archives in Psychiatric Nursing in December 1995, Krauss emphasized that in managing costs and care, psychiatric nursing must make mental health systems humane. She advocates that the core of psychiatric nurses work is "therapeutic engagement with patients." The PPCNP is an example of this notion, a mesh of psychotherapeutic skills, of neurobiological knowledge, behavioral interventions, and physical assessment skills.

Advantages

There are several advantages to the psychiatric NP role. According to AACN, the crisis in today's health care system results from high costs, limited access, and concerns about quality (AACN Position Statement, p. 2). The Psychiatric Nurse Practitioner offers advantages by addressing these three issues: high cost, limited access and quality by providing psychotherapy and physical assessment skills in cost efficient, at on-site clinics and with improved quality. The Psych NP can:

• Refer mentally ill patients who need a more specialized or complex workup to the primary care physician and/or specialist;
• Provide on-the-spot health promotion and preventive services for medical problems;
• Provide routine physical health screening;
• Offer continuing primary health care for routine physical problems, saving both patient and facility additional hospital/medical costs; and
• Conduct short term psychotherapy and psychoeducation.

A second advantage is the flexibility of the psychiatric NP. (Taylor (1995), in an editorial, stated: "It is my understanding that only those professions that are flexible, able and willing to competently perform a variety of tasks are going to thrive in a managed care environment. Psychiatric nurses are certainly in a position to demonstrate that flexibility if we choose to do so." (p. 232). The psychiatric NP is an exemplar of flexibility.

Changes in the health care delivery now place advanced practice nurses, including psychiatric nurse practitioners, in a position to provide a broader array of services, drawing on their skills in assessing common medical problems and capability in making appropriate referrals for specialist consultations. Persons with chronic mental illness have a high incidence of both acute and chronic medical problems, according to available literature. (McConnell, Inderbitzin, and Pollard ,1992) described the role of NPs who provide physical health assessment with chronic mentally ill patients in community mental health centers. The authors suggested that the chronically mentally ill have numerous physical health problems, and may refuse to seek medical consultation. Patients seen for psychotherapy also often have concomitant heart disease, diabetes mellitus, gastrointestinal or genitourinary disease. Additionally, physiological side effects of antidepressants and antipsychotic medication often prescribed in conjunction with psychotherapy often necessitate monitoring of the patient. McConnell et al (1992) describe a nurse practitioner and medical doctor who assessed forty chronic schizophrenic patients in a psychiatric outpatient clinic and found, "patients had an average of five medical problems, including an average of two previously undiagnosed problems." (p. 726).

The following four circumstances define on-going concerns of interest to the Psychiatric Nurse Practitioner and become additional advantages for the NP role:

• Not all chronic, mentally ill patients receive adequate medical care. Psychiatric symptomatology is often so blatant that the medical staff overlook underlying physical problems and/or medical symptoms.
• Many of the mentally ill do not have a family support network (or an interested family member or friend) to accompany them to the medical doctor's office to assure conveyance of physiological disorder.
• Psychiatric patients frequently suffer from thought disorders or depression and subsequently have impaired information processing or concentration. Their comprehension of treatment regimes may be inadequate and contribute to non-compliance.
• Lastly, few mental health workers in out-patient settings perform physical exams as part of routine evaluation.

Worley, Drago and Hadley (1990) also emphasized the need to address physical health needs of the chronically mentally ill patients. They noted that the rate of physical illness among individuals with diagnosed psychiatric conditions are higher than that in the general population. (Worley, et al, p. 108). They suggested that the chronically mentally ill's use of general health services is limited because of internal and external factors. Internal factors refer to the active psychiatric symptomatology of the mental disorders. External factors include the availability and access of general health care service and training of personnel. Health care workers may withdraw from the psychiatric patient because of their inexperience and lack of knowledge of psychiatric symptomatology, reiterating the practicality of the role of Psychiatric Nurse Practitioners.

Tusaie-Mumford (1994) suggested that advanced practice psychiatric nurses have increased sensitivity and skill in conducting physical assessments as she discussed a schizophrenic client with tactile/and auditory hallucinations who died of cardiac problems.

Vousden (1985) described a British nurse who worked half-time in traditional medical nursing combining technical skills and psychotherapy. This was an early root of today's psychiatric nurse practitioner in the United States. The British nurse, who worked with a general practitioner, related: "Many patients come to me for cervical smears, dressings or whatever and in conversation it becomes apparent that they have got other problems. They may look distressed or burst into tears. Soon they start to talk about whatever it is that is creating the anxiety and make further appointments to see me, just to continue with the counseling." (Vousden, 1985, p. 46)

To summarize advantages, the psychiatric NP can function in a variety of settings particularly outpatient behavioral managed care centers where short-term therapy is the model. The psychiatric NP can be credentialed in two manners through the American Nurses Association (ANA) and through the state of Pennsylvania as a NP, making the person more marketable and cross trained. Smoyak (1993) said "Cross training in psychiatric nursing is here to stay; stop fighting it and get on with it." McLean Psychiatric Hospital in Massachusetts now requires that psychiatric nurses take a physical diagnosis course and a basic general pharmacy course according to Nancy Valentine, Administrator at McLean Hospital (Brooks & Valentine, 1993). Psychiatric nursing needs a blend of the interpersonal and biological to provide psychiatric care; to capitalize on the therapies that have measurable outcomes and demonstrate effectiveness.

In reviewing the literature, there are few articles on psychiatric nurse practitioners. The psychiatric NP is not a new concept; what is new is the educational programs to train such a person in the United States. Lego (1995) suggested that educators not eliminate clinical nurse specialist psychiatric nursing graduate programs, but offer both CNS and NP programs. Haber and Billings (1995) describe a primary mental health care model for psychiatric nursing. "Primary mental health care involves all the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention of mental illness, and health maintenance, and includes the management (treatment) of and/or referral for mental and general health problems" (Haber & Billings, 1995, p. 155).

Conclusion

What have we gleaned from the literature? The psychiatric nurse practitioner is a controversial issue; yet a difference of camps brings about paradigm shifts and adds to the field. One cannot foresee into the future, but one does know that psychiatric nursing, as a subspecialty, must recruit more young students into the field. In order to do that, changes need to be made in accordance with the changing times. Psychiatric nursing does not have the luxury of providing long-term therapy to patients whose insurance will cover only twenty sessions. Many acute care psychiatric inpatient units have an average length of stay of seven days. The advanced practice psychiatric nurse must become cognizant of the major changes in the "real" world and adapt educational programs of training to the short-term models to combine psychiatric skills with some physical diagnosis skills. It is not so aberrant, after all, that the master level psychiatric nurse was originally trained in physical assessment through the bachelor's level nursing education.

In Archives of Psychiatric Nursing, February 1996, editor Judith Krauss discussed an editorial related to what is best for the public interest. She raised the issue about designing managed care systems and the many stakeholders. She suggested that the profession "must design systems that improve access to care, better coordinate care, integrate principles of care, efficiency and cost, and measure quality through outcomes and evaluation." (p. 1) This is what the new psychiatric nurse practitioner does. He/she is prepared to work in the ever changing health care system. He/she has a blend of interpersonal theory, with a heavy emphasis on the short-term approaches; is grounded in the latest neurobiology and psychopharmacology, and is knowledgeable of the short-term family models of care. What is different is the fact that she or he is cross trained in medical management of common medical diseases and can do a physical exam when needed, is aware of physical diagnosis and common disorders. The psychiatric NP can do therapy and be able to screen for diabetes or hypertension in his depressed client and to rule out somatic delusions or pain associated with tendinitis in her schizophrenic client. The psychiatric NP may not be for all, but offers an optional but important role in advanced practice psychiatric nursing.

Author

Kathryn R. Puskar, RN, DrPH, CS, FAAN

Assistant Professor
Department of Health & Community Systems
University of Pittsburgh
School of Nursing
3500 Victoria Street, Room 415
Pittsburgh, PA 15261
Email Address: kpu@med.pitt.edu

Dr. Kathryn Puskar received her Nursing Diploma from Mercy Hospital School of Nursing, Johnstown, PA. Dr. Puskar holds a bachelor's degree in Nursing from Duquesne University, Pittsburgh, PA, a master's degree in Psychiatric Mental Health Nursing, and a masters degree in Public Health and a doctoral in Public Health from the University of Pittsburgh. She is a fellow of the American Academy of Nursing, a certified clinical nurse specialist in adult psychiatric nursing by the American Nurses' Association, and has been presented the Distinguished Lecturer Award by Sigma Theta Tau. Dr. Puskar has funded research in the area of stress and coping in women and adolescents, has published 50 papers and delivered over 35 national/international presentations. Presently she is a faculty member at the University of Pittsburgh School of Nursing, Department of Health and Community Systems.