Introduction

It was the first day of the required nursing issues course in my final semester of graduate school. The instruction was to introduce ourselves to a peer as an exercise in professional networking. My assigned partner was a student completing her master's degree as an adult nurse practitioner. She asked, "Are you going the nurse practitioner route?" I responded that my focus was as a psychiatric nurse clinical specialist. What followed is what has become a typical response: "Oh . . ."

I immediately experienced a flashback to my earlier years as a professional novice. I would proclaim and defend my clinical career choice as a psychiatric nurse. The most frequent retort was, "Oh . . . !" or "Aren't you going to lose your medical skills?"

Twenty years of experience and three years of graduate nursing education have not changed the received response. There is a general misperception surrounding the role of the psychiatric nurse both in the public and professional sectors. Does this most recent reply from my graduate peer reflect the persistence of ambiguity into the advanced practice nursing arena?

Clarity indicates a clear understanding of a situation or issue. Parity connotes equality in a circumstance or function. Parity and clarity in professional roles is pertinent to our changing health care climate. Clarity of scope of practice will assure the highest quality and most cost-efficient care for clients. Parity of practice will give the client options for receiving the most appropriate care in a given situation. Parity and clarity are essential components of the advanced practice nurse domain. They will define the extent of nursing practice and increase the options for quality client care.

The exuberance in establishing the role of the psychiatric nurse practitioner (NP) has placed the psychiatric clinical nurse specialist (CNS) in a misunderstood and often devalued position. Federal funding of graduate programs for NPs and downsizing of hospitals who formerly employed CNSs have led to this change in advanced practice focus (Lego, 1996).

Public attention of the need for primary health care in this country has heightened awareness of the existence of advanced practice nurses. Confusion begins when trying to ascertain who is providing this care for the mental health client.

My purpose is to clarify the role of the psychiatric clinical nurse specialist by re-examining some commonly held assumptions. The first commonly held assumption is that the psychiatric CNS is competent only in talking therapy. A second assumption is that therapeutic communication is practiced by all professionals. A final assumption is the belief that the generalist is able to provide adequate and cost-effective care to the mental health client.

Initially, a brief historical review of roles is presented. Second, three specific areas are addressed as they pertain to the psychiatric APN role of boundaries, distinctive skills, and multi-functionality. Boundaries are the periphery in which the psychiatric CNS practices. Distinctive skills are areas of proficiency. Multi-functionality of role encompasses the realm of care.

Historical Perspective

The clinical nurse specialist (CNS), a role dating back to the 1960s, was an attempt to bring nursing expertise to the bedside in a fragmented post-WWII health care system (Cukr, Jones, Wilberger, Smith & Stopper, 1997). These early CNSs provided social and psychological support to their clients, served as a role model to nursing staff, provided consultation to other disciplines, and conducted nursing practice outcomes research (Cukr et al., 1997). These master's prepared nurses encountered difficulties, however, because their cost-benefit was not easily or directly documented.

The educational preparation of psychiatric CNSs expanded with the provision of financial support with the National Mental Health Act of 1947. This post-WWII legislation dispensed funds to mental health professionals, which included nurses (Cukr et al., 1997). Hildegard Peplau established a program at Rutgers University in 1954 which graduated the first nurse psychotherapists who were CNSs. The psychiatric CNS has always maintained a direct patient care role.

The nurse practitioner (NP), a role also dating back to the 1960s, was the result of the perceived shortage of physicians. NPs were originally credentialed by certificate programs or continuing education which did not offer college credits. The functional role of the NP was the use of technical skills to achieve cure or maintain wellness.

The psychiatric nurse practitioner (PNP) role developed as biological psychiatry began to strengthen with acceptance of the pathophysiological basis for schizophrenia and other chronic mental disorders. This physical/biological care component was addressed by the NP. The CNS, theoretically, provided psychotherapy while the NP delivered physical care.

The debate over the definitive characteristics and blending of the nurse practitioner (NP) and clinical nurse specialist (CNS) roles in psychiatric nursing is currently reflected in the literature (Caverly, 1995; Cronwett, 1995; Elder & Bullough, 1990; Fenton & Brykczynsk, 1993; Lego, 1996; Moller & Haber, 1996; Puskar, 1996; Talley & Caverly, 1994). The CNS proponents of the blended role view similarities in function, overlapping practice, and economics as advantages of a single specialization. Dissenters point out the historical etiology of the roles, divergence in the scope of practice, and unrealistic expectations of a "super-psychiatric advanced practice nurse" who can know all and be all.

Assumption #1: Boundaries

There is an unwritten assumption that the psychiatric clinical nurse specialist (CNS), as well as the basic prepared psychiatric nurse, is competent only in "talking therapy." A conscious choice to perfect psychotherapeutic proficiency does not preclude basic knowledge of fundamental nursing assessment skills. Psychiatric nurses have consistently been on the forefront of the delivery of safe and humane care for the mentally ill client. Holistic provision of care for these clients is certainly not a new concept. Even the novice psychiatric nurse will have enormous difficulty separating the "psyche" from the "soma."

A DSM-IV diagnosis has never been a fail-safe guarantee against physical illness; quite the contrary.

Schizophrenics commonly display symptoms of water intoxication, substance abusers often present compromised cardiac status, persons with eating disorders frequently have fluid and electrolyte imbalances, and depressed patients have been known to have cholecystectomies!

The antipsychotic, antidepressant, and anxiolytic medications frequently used in psychiatric care often produce physical complications which include constipation, blurred vision, hyperkinesia, tardive dyskinesia, postural hypotension, agranulycytosis, extrapyramidal symptoms, anticholinergic symptoms, sedation, metabolic and endocrine imbalances, and cardiac and vascular side effects. It has always been prudent and necessary for psychiatric nurses to make thorough mental and physical assessments of their patients. This includes E.K.G. results, routine lab tests, renal function studies, CPK levels, vital signs, overt and subtle signs and symptoms of illness, and changes in mental or somatic status. Again, we are not entering unchartered territory. The APPN has had the benefit of advanced education and often substantial clinical experience to make these assessments at a more comprehensive level.

Assumption #2: Distinctive Skills

A second assumption is that anyone can, and does, therapeutically communicate. Since all behavior is communication, I suppose we all communicate in some manner. Therapeutic communication, however, is a learned and developed technique. This includes recognition of double-binds, use of therapeutic double-binds, cognitive restructuring, directives, relabeling, metacommunication, and identification of communication patterns. It is worth noting that command of technical skills are typically more valued than mastery of interpersonal competence. As O'Toole and Welt (1989) point out, two major challenges plague the mental health client: relatedness and communication difficulties. The skill in understanding and operationalizing interpersonal and communication theories is paramount for competent mental health care. Most nurses, with the exception of APPNs, have not had formal training in therapeutic communication since their first psychiatric nursing course. A single undergraduate psychiatric nursing course does not assume skillful communication between client and nurse anymore than my medical-surgical course twenty years ago assures proficient care of a newly-incised draining wound!

The efficacy of communication skill is not readily measured. Physical intervention is directly measurable and subsequently valued. Since communication effectiveness is more ambiguous, an incorrect assumption is the deceiving simplicity of "talking therapy."

When we arrive at the advanced practice domain, the stakes are high. The NP is expected to deliver primary care at less expense to the health care agency. The NP is well versed in pathophysiology, physical assessment, and biology. It is dangerous to assume that they are expert in therapeutic communication which is the funnel to quality health care for the mentally ill client.

I will not elaborate on the psychological/biological, nature/nurture, genetics/stress positions of illness etiology currently debated in literature. Several indices are worth noting.

Patients presenting psychosomatic symptoms of depression initially see a generalist, rather than a specialist, 85% of the time. It is estimated that 20% of elderly patients in acute care settings are abusing alcohol or other substances. Most patients who suicide have seen a primary health care provider within one week of the successful attempt. It is evident that a comprehensive approach in the care of the mentally ill client is essential in therapy (and with therapists). The issue is not whether one specialty can do it all; the question is how do we deliver this care most effectively.

Psychiatric nursing concentrates on the "promotion of optimal mental health, the prevention of mental illness, health maintenance, management of, and/or referral of mental and physical health problems, the diagnosis and treatment of mental disorders and their sequelae, and rehabilitation" (Haber & Billings, 1995, p. 155). The APPN, whether a CNS or NP, functions as psychotherapist, diagnostician, and psychopharmaceutical dispenser. If we delegate neurobiology to the psychiatric nurse practitioner, should we leave psychotherapy to the clinical nurse specialist? Aren't we trying to separate "psyche" from "soma" again? Haven't we learned that this doesn't work? Nursing's anchor has traditionally been the provision of holistic care which is the advantage of having a nurse therapist in lieu of alternative counseling disciplines. Separating the care of body, mind, and spirit is dangerous. We might just be shooting ourselves in the advanced practice metatarsal.

Assumption #3: Multi-functionality of Roles

A third assumption is that a generalist can singularly provide appropriate and cost-effective care to the psychiatric patient. I agree with "additional physical assessment, neuroscience, and clinical psychopharmacology" (APNA Position Statement, 1997) for regulatory guidance with prescriptive authority for APPNs. I find it curious that the APN who is the primary care provider of adults, the adult nurse practitioner (ANP), is not required to take additional therapy or communication courses. The same is true for the pediatric nurse practitioner. With these practitioners on the front lines of care delivery for the general and psychiatric populations, it is reasonable that enhancement of their communication skills is equally significant as the additional assessments skills are for the APPN. It is also relevant that NP graduate curriculum in PMH programs have substantially more hours spent on advanced physiology and pharmacology coursework than on psychopathology, family and group modalities, and individual therapy.

In the year 2000, depression will be the fourth leading cause of death in the United States. Approximately one million children and adolescents in the United States suffer from obsessive compulsive disorder (NAMI Helpline Fact Sheet, 1997). Of the Americans over the age of sixty-five, numbering 33 million, five million suffer from symptoms of depression (Lebowitz, 1997). Most of the individuals who are at risk visit a primary care physician the same month that they successfully attempt suicide (NAMI Factsheet, 1997). With changes in the delivery of health care, these facts become paramount when considering how health care is transferred between APNs and other health care providers. Has the preparation for adult nurse practitioners and pediatric nurse practitioners changed with the growing incidence of psychiatric/mental health issues presented in primary health care?

The psychiatric CNS is typically certified in either adult or child/adolescent psychiatric-mental health nursing. Qualified to practice independently, these nurses have developed psychotherapeutic skills as well as maintaining basic assessment and pharmacotherapy knowledge. Since psychosocial therapies are fundamental in the treatment of anxiety, depression, obsessive-compulsive disorders, schizophrenia, and most other psychiatric disorders, the specialist who is skilled in these therapies is essential in the delivery of care for the mental health client.

Whether clients find their way to this professional will depend on comprehension of roles by the adult nurse practitioner, pediatric nurse practitioner, psychiatric nurse practitioner, and all other health care providers. The primary clinician who initially sees the client must facilitate appropriate referral. Most managed care organizations recognize the psychiatric mental health CNS as a provider due to the high educational standards leading to ANCC certification (Lego, 1996).

The expertise of adult and pediatric nurse practitioners is not traditionally in therapeutic communication or psychotherapy, even though they may possess basic skills in this area. Interestingly, the American Academy of Nurse Practitioners (Position Statement, 1993) cites that "Teaching and counseling of individuals, families, and groups are a major part of the nurse practitioner's activities." Access to appropriate care, provided by the psychiatric mental health CNS or NP, is often funneled through other practitioners. Awareness of limitation in scope of practice and referral to the appropriate professional to provide these services will assure competent, efficient, and cost-effective care.

Conclusion

Role confusion exists between advanced practice psychiatric nurses who are CNSs and NPs, between adult nurse practitioners and APPNs, between basic and advanced psychiatric nurses, and between other mental health professionals and psychiatric nurses. Clarity and parity have escaped us.

The turf battle supported by the "psyche versus soma" mentality has reached the advanced practice arena. The casualty could be the mental health client. We have a timely responsibility to clarify our roles, conscientiously promote our expertise, and realistically recognize our limitations. Collegiate forums provide a place for this discussion to begin for the new class of advanced practice nurses. Understanding practice roles is necessary for professional networking. It is vital that we continue the dialog to enlighten each other, as well as the public, so that competent and continuous care is provided for the mentally ill client and family.

Author

Laura M. Paisley, BSN
E-mail: lpaisley@kent.edu

Laura Paisley is a psychiatric/mental health nurse practicing in acute care hospital settings in Northeastern Ohio. She is a certified psychiatric/mental health nurse and has worked primarily in inpatient psychiatric clinical care for the past 20 years. She is currently completing her MSN in Psychiatric/Mental Health Nursing at Kent State University.