Archives of Psychiatric Nursing 28 (2014) 298–300
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Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
Guest Editorial
The Evolution of the Role of the Psychiatric Mental Health Advanced
Practice Registered Nurse in the United States
ABSTRACT
I recently met with an undergraduate nursing student who was
interested in psychiatric mental health (PMH) nursing. She specifically
wanted to know about the role of the PMH advanced practice registered
nurse (APRN). That conversation took considerably more time than it
might have taken in 1987 when Dr. McBride and her colleagues
evaluated the effect of a PMH clinical nurse specialist (CNS) on nursing
communication and work environment in a state psychiatric hospital
(McBride et al., 1987). A great deal has changed since that time with
regard to advanced psychiatric nursing practice and the mental health
care environment. PMH advanced practice registered nursing (APRN)
has evolved to fill a variety of niches as mental health care delivery has
been transitioning away from traditional hospital-based care. The
purpose of this paper, then, is to explore the changes in the role of the
PMH APRN in the U.S. that have occurred since the first issue of Archives
of Psychiatric Nursing was published in 1987.
THE PRIMARY ROLES: CLINICAL NURSE SPECIALIST AND
NURSE PRACTITIONER
The PMH CNS was the first master's prepared advanced practice nurse of
any specialty; a role shaped by Hildegard Peplau as she developed the
graduate program at Rutgers University in 1954 (Rust, 2004). Under
Peplau's direction, the emphasis of the CNS graduate program grew to focus
on the development of skills in psychotherapy (Spray, 1999). Competencies
also included organizational analysis and consultation service—a systems
understanding of nursing, healthcare delivery and the change process (A. W.
O'Toole, personal communication, March 3, 2014). PMH CNSs, then, also
provide consultation and liaison services and support and education for
nurses, other healthcare providers, families and patients. These were the
primary CNS tasks that were evaluated by McBride et al. (1987). Graduates
from Rutgers, and programs that were later developed, assumed positions in
hospitals, community mental health centers, and private practice. CNSs were
certified to provide services to adults and, later, to children and adolescents.
The PMH NP role was introduced in the early 1990s and legitimized
with the development and availability of a certification exam for adult and
family PMH NPs in 2001 by the American Nurses Credentialing Center
(ANCC; Bjorklund, 2003). The role was designed to address multiple forces
in the healthcare environment including a substantial body of research
that demonstrated the relationship between neurobiologic processes and
mental illness and growing recognition of the need for primary mental
health services and mental illness prevention (Delaney, 2005). Therefore,
the knowledge and skills needed for both physical and mental health
assessment were considered critical. While initially there was variation in
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educational preparation for PMH NPs, competencies developed by the
National Panel for Psychiatric-Mental Health NP Competencies (2003)
helped to standardize curricula, to some degree (Delaney, 2005).
The development and growth of the PMH NP role did not create a
happy situation for many PMH CNSs as evidenced by heated exchanges at
professional meetings and published commentary (see Delaney, 2005 for
an excellent review). The rate of certification of PMH NPs was on the rise
as the number of PMH CNS certification applicants was declining
(Delaney, 2009). Additionally, there was clear evidence that the
competencies (American Nurses Association, American Psychiatric Nurses
Association, & International Society of Psychiatric-Mental Health Nurses
[ISPN], 2014; Rice, Moller, DePascale, & Skinner, 2007) and educational
programs were more similar than different. This was particularly true after
the establishment of core competencies for the graduate education of all
advanced practice nurses that included courses in pathophysiology,
physical assessment, and pharmacology (the 3 Ps; American Association
of Colleges of Nursing [AACN], 1996), that up until that time were often
lacking in PMH CNS programs.
The primary PMH nursing associations, APNA and ISPN, solidified their
position on PMH APRN roles in response to the Consensus Model for APRN
Regulation, a document developed through the collaboration of nursing
educational, accreditation, certification and licensing bodies across the
United States (National Council of State Boards of Nursing, 2008). The
Consensus Model provides guidance to states to adopt regulation of
APRNs that is uniform across the country. APNA and ISPN convened a joint
task force of PMH nursing leaders to develop recommendations for
implementation of the Model for PMH APRNs (Farley-Toombs, 2011;
Regan-Kubinski & Horton-Deutsch, 2012). The task force forum also
provided an opportunity to plan for the future of PMH advanced practice
after careful consideration of the Consensus Model, trends in PMH APRN
certification, transformation of the healthcare environment, changes in
practice based on science, and the mental health needs of the population.
The primary recommendation was that “there will be one entry
educational focus for the future: PMH NP with preparation across the
lifespan, addressing mental health promotion and mental illness diagnosis
and treatment” (APNA, 2011). Psychotherapeutic modalities were
identified as essential content in educational programs (the fourth “P”).
Additionally, PMH APRNs would continue to be able to practice under
their current license and certification. The boards of both APNA and ISPN
unanimously endorsed the recommendations.
PRACTICE PATTERNS THEN AND NOW
In 1988, around the time of the study conducted by Dr. McBride and
her colleagues, there were a total of 3497 PMH APRNs certified by ANCC
 Guest Editorial
as adult or child and adolescent CNSs (Peterson et al., 1996). By 2012,
there were over triple the number with over 13,000 certified PMH CNSs
as well as NPs (N. Croce, personal communication, March 6, 2014) but
the rate of growth in numbers of PMH APRNs is still discouragingly slow.
There are only a few comprehensive surveys of PMH APRN
practice, the most relevant for the purposes of this paper in 1995
(Peterson et al., 1996) and 2007 (Drew & Delaney, 2009). While these
sources do not allow a precise comparison of practice in 1987 and
2014, general trends in practice patterns of PMH APRNs over 27 years
can be examined. There were 6030 certified PMH CNSs in 1995. The
PMH NP certifications were relatively new and complete data were
not available, so NPs were not included in the 1996 report. In 2007,
however, 20% of the 10,001 certifications were for PMH NPs (ANCC,
2008; Drew & Delaney, 2009). This trend in certifications is continuing
with nearly 46% of the PMH APRN certifications for NPs (N. Croce,
personal communication, March 6, 2014).
Slightly more PMH APRNs were employed full time in 1995, 76%
compared to 68.6% in 2007 with 85% providing direct care in 1994
compared to 93% in 2007. An estimated 49% worked in outpatient
settings (clinics, individual, and group practice) in 1995; 65% in 2007.
This suggests a transition from hospital-based care with approximately
29% of PMH APRNs employed in hospitals in 1995 and 20% during 2007.
Perhaps the greatest shift in role definition was due to the addition
of prescriptive authority to the scope of practice of PMH APRNs.
Beginning in the 1980s with some states granting prescriptive
privileges to some APRNs (Talley & Brooke, 1992), psychotropic
medication evaluation, prescription and management have become a
routine part of clinical practice for many PMH APRNs, now in all states.
Campbell, Musil, and Zauszniewski (1998) reported that 20% of PMH
APRNs were prescribing in 1994. The proportion of prescribing PMH
APRNs increased to 68% in 2007 (Drew & Delaney, 2009).
The educational emphasis of the core APRN curriculum on pharma-
cology, physical assessment and pathophysiology along with the PMH
specialty focus on psychotherapy modalities across the lifespan reinforced
the value of the traditional consultation and liaison role (McCorkle et al.,
2009) and resulted in a practitioner with a combination of skills that are
desperately needed across systems of care. PMH APRNs are more likely
now than in 1987 to be working in non-traditional settings—that is,
settings whose primary function is not to provide mental health services
but they are, nonetheless, called upon to do so. Examples of such
workplaces include correctional settings (Kent-Wilkinson, 2010), emer-
gency departments (Nicholls, Gaynor, Shafiei, Bosanac, & Farrell, 2011),
and schools (DeSocio, Elder, & Puckett, 2008).
An additional health care setting that is ripe for advanced
psychiatric nursing practice is the primary care clinic. Health care
reform and the Affordable Care Act (ACA) have directed greater
attention to health care practice that promotes holism, prevention of
mental illness, and mental wellness promotion. With a large body of
evidence that mental and physical health are inextricably linked
(Weiss, Haber, Horowitz, Stuart, & Wolfe, 2009) and direction from
government policy-makers, many models for integration of primary
care and behavioral health services have been developed (Substance
Abuse Mental Health Services Administration, n.d.). Given their
educational preparation, PMH APRNs are ideally suited to provide
service in settings that integrate primary and behavioral health
services (Delaney, Robinson, & Chafetz, 2013).
CONCLUSION
There is nothing like a walk back in time to be reminded of how the
roles of psychiatric mental health nursing have evolved, sometimes
with great turbulence, but always with great passion for our patients.
I am grateful for the vision of Hildegard Peplau and her students who
disseminated her traditions of patient-focused care, theory- and
research-based interventions, and leadership in the profession of
nursing. My gratitude extends to the scholarship of Dr. McBride and
299
her colleagues whose work was among the earliest evaluations of the
PMH advanced practice nursing.
It is evident from this review that the advanced practice role of PMH
nurses has adapted to meet the needs of society. As one of the five core
mental health disciplines (Health Resources & Services Administration,
n.d.), there is a grave responsibility to continue to do so. What is also
clear is the need to strengthen the PMH APRN workforce as health care
reform is likely to increase demand for mental health services. This will
require a rigorous graduate curriculum that is regularly updated to
include emerging evidence-based practice (Hoge et al., 2013); political
activism to address regulatory barriers to the full scope of practice; and a
systematic plan to increase and strengthen the PMH APRN workforce
(Hanrahan, Delaney, & Stuart, 2012).
Barbara L. Drew
College of Nursing, Kent State University, Kent, OH
E-mail address: bdrew@kent.edu
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