Role, Responsibilities, And Competencies Of A Psychiatric Mental Health Nurse Practitioner

It is widely known that competencies are necessary in nursing practice and drive the improvement of not only advanced nurse practitioners, but Psychiatric Mental health Nurse Practitioners (PMHNP) as well. Specialized master’s prepared nurse programs have been available since the 1950s with the first nurse practitioner school being available in 1965.. The number of schools has grown exponentially and provides education to nurses in the health care environment. Prescriptive authority for the PMHNP’s role was added in the 1980s and currently, all states allow PHMNPs to prescribe medications and provide counseling to patients. We will discuss how the roles and responsibilities relate to PMHNP competencies through Hameri’s Seven Advanced Practice Nurse Competencies. In particular, consultation, collaboration, and expert coaching and guidance of client/families will be discussed in-depth. These competencies will be analyzed in relation to an interview of a practicing PMHNP.

The PMHNP interviewed, Robin Coleman, currently practices in private practice at Cornerstone Counseling in Brookfield, Wisconsin. She earned her graduate degree at the University of Wisconsin-Madison. Robin has been practicing for more than 15 years in Southeast Wisconsin in inpatient settings, outpatient settings, youth treatment centers, and nursing home facilities. While Robin works with clients of all ages, she most enjoys working with children and adolescent clients. This paper will discuss how Robin’s roles and responsibilities relate to current practice.

Direct clinical practice

In psychiatric mental health nursing, direct care is the central competency that impacts the six competencies. Each of the competencies rely on direct clinical practice because it impacts clinical credibility. This is completed by gaining rapport with clients and individualizing the treatment plan, all while providing holistic care to the client. When this is completed, clients have a foundation for success.

The direct care competency is essential when providing direct patient care is significant, especially at a master’s prepared nursing level. Advanced practice nurses must build upon their knowledge of pathophysiology, pharmacology, and physical assessment. PMHNP’s must also have advanced knowledge of psychopharmacologic medications as they relate to the clients they serve. This knowledge will be utilized across a continuum of client populations. This allows PMHNPs to integrate evidence with the client’s values, and clinical judgment to best care for the clients. The direct care competency impacts all of the competencies, including consultation.

Consultation

When discussing competencies of a PMHNP, consultation is paramount. Consultation is defined as a deliberation on a case or its treatment. Not only does consultation increase the access clients have to a PMHNP, but it allows other health care professionals to increase their knowledge of mental health by use of expertise information that can be provided by a PMHNP. This in turn allows for high quality and cost effective care to be provided throughout the health care system. PMHNPs have a unique nursing perspective that is irreplaceable to the consultation process.

Wait periods for mental health treatment are increasing and initial psychiatric evaluation appointments are greatly needed. Robin discussed the stress of providing initial psychiatric evaluations because the need for established psychiatric evaluations increases with each new client. A supportive Psychiatric Bridging Intervention consisted of counseling and prescription medication was utilized between the time of the intake appointment, where a patient is seen within one week of calling the office, and the initial psychiatric evaluation, which may occur up to three months later. The authors of the article found not only did adherence of appointment attendance increase, but the length of the appointment was found to be too great and 30 minutes was sufficient, rather than 60 minutes. This is significant because PMHNP’s are able to see twice as many patients while providing the same quality of care, the patients are able to obtain support prior to the initial psychiatric evaluation. When this article was mentioned to Robin, she felt 30 minutes was not sufficient to build a rapport with a patient in addition determine what treatment plan is best. The lack of initial psychiatric evaluation appointments not only provides a stress on potential clients, but also the PMHNPs who must provide opportunities for clients to be seen.

Peplau’s Theory, in regard to the orientation phase, is the assessment of the patient’s overall health and situation and acknowledges the challenges faced with new populations. When new to the role of a PMHNP, building rapport can be difficult, according to Robin in part due to time constraints, but also feeling self-conscious about making a mistake. Robin assured me this is typical and does not last long. Robin also identified that the role goes beyond assessing, diagnosing, and providing treatment plans, but extends to counseling, despite the time constraints. This is significant as in my interview, I was informed that every patient population is unlike another, but what is truly different is that each patient is an individual and requires a unique treatment plan. Robin felt strongly that the counseling portion of the consultation is “where I really get to know my clients”. Everyone is to be treated as a human being, which is the center of Peplau’s Theory.

Collaboration

Collaboration is fundamental when discussing a successful PMHNP. Collaboration is defined as working jointly with others, especially intellectually. To be able to effectively collaborate, PMHNP must be competent clinically and respect one another. This is significant because if one contributor does not participate effectively, the end result of increasing knowledge and providing excellent care of the client may not be achieved. Being engaged in solving the problems of the client are of great importance. No two clients are alike and must be regarded as such. Successful collaboration is imperious as patient outcomes are improved because each client is unique.

Collaboration among providers is key to the success of care for clients. Elsom, Happell, and Manias (2009) found that opposing vantage points are present in Australia regarding the practice of medical practitioners and the expanded practice role of nurses. The role of the nurse practitioner is to aid in the health care system, not take it over. What is interesting is that medical practitioners responded favorably to the role of the Nurse Practitioner. It is critical to work in conjunction with one another to provide the best care possible to the clients. This aligns with King’s conceptual system, which is based on the knowledge that all human beings are the focus of nursing. Due to the ongoing changes of the health care environment, collaboration between health care professions is essential to improve care of the client and client outcomes.

Expert coaching and guidance of clients and families

When one mentions the term “coaching,” many would think of sports because coaching is defined as one who instructs or trains. Coaching can also be applied to PMHNPs as new ways to prevent illness from occurring or progressing. This is key when discussing the role of the PMHNP. While it might be assumed that the PMHNP only provides care for the mental health illness, but in reality, the PMHNP must provide care for the entire patient. PMHNPs must also include the client as well as their support systems, values, cultural needs and preferences.

When determining treatment plans for clients, PMHNPs must take into account the ability of the client and their families to partake. PMHNPs must be prepared to use alternate routes to ensure the treatment plan is successful. It is the PMHNP’s responsibility to combine holistic care of the client with the knowledge gained through formal education. This responsibility should not be taken lightly as it has the ability to change client outcomes. PMHNP’s should improve their clinical practice as new evidence is published in order to provide the best care possible. This is frequently completed by seeking out information and participating in extracurricular learning experiences. Supporting one another, both within as well as outside of the psychiatric mental health field is significant to encourage the growth of everyone as learning never ceases.

Expert coaching is completed among peers, but also with clients. The PMHNP must be able to encourage and empower clients to make progress in regard to their treatment plan. PMHNPs must be able to take the time to learn how to become an effective coach. Coaching is a competency a PMHNP must possess.

Robin detailed her experience of beginning her career in PMHNP after graduation. Not only did she relay that she was terrified of making a mistake, one that I share, but knowing that there are resources available pre, during, and post-consultation. She informed me of a time when she was meeting with a client for the first time and became so nervous, she simply asked questions on the initial psychiatric evaluation form that she wasn’t truly listening to the clients responses. At the end of the consultation, Robin stated she felt like a fraud for expecting the client to pay for services she did not fully provide. She called the client and asked the client to return so a proper initial psychiatric evaluation could be completed. She said she learned a powerful lesson that day because not only did she recognize how her own insecurities played into her practice, but the expectations she had for herself were not being met. In the end, Robin stated there is no shame in having to look up a dosage for a medication or symptom of a diagnosis if it means better and more comprehensive care is being provided to the client.

During the interview, Robin stated that patients may not always complete their portion of the treatment plan. When this occurs, Robin advised me to ensure a rapport has been established, determine if any barriers are present, and document thoroughly the education that was provided. This was interesting because my inclination was that in private practice, the clients would be more inclined to complete their portion of the treatment plan due to financial responsibilities that are present. Robin informed me that throughout her experience, no one setting has clients that fully comply with their treatment plan, which is why frequent revisions are completed.

Peplau’s Exploitation Phase, uses problem-solving techniques to better understand the underlying problem. When the client feels integrated in the solution, there is likely to be greater adherence to the desired outcome. Utilizing techniques that explore and help determine the underlying problem are essential to success. This is significant because patients must feel incorporated into the plan to have a chance at success.

Conclusion

Masters prepared PMHNPs are influential in the delivery of care that is provided to clients. PMHNPs must have an understanding of competencies and theories of what drives the care of clients and populations. Direct care, consultation, collaboration, and expert coaching and guidance of clients/families are among Hameri’s Seven Advanced Practice Nurse Competencies. Incorporating these competencies into practice is essential in the ever changing health care system. PMHNPs are indispensable and their expert knowledge aids in improving the lives of the clients they serve.