Dr. Nurse at Work

After months of board exam preparation, applications, interviewing, and soul-searching, I recently accepted a position as a hospital mental health consultant, or as I like to call it, Mighty Mouse. I start Monday.  I am excited to get to practice and am ready to meet the challenge of what I see as an enormous responsibility to ensure patients are followed by the correct services to meet their immediate needs.  When working as an RN in Emergency Psychiatric Services, I saw first hand how having "bipolar" or "schizophrenia" on one's chart would often result in being immediately shipped from ER to EPS, even if chest pain or severe headache was the primary complaint.  This stigmatization (or perhaps clinical laziness) can lead to disastrous outcomes for patients with mental illness who are actually having an emergent physical issue.  Psychosis, delusions, and mania are not exclusive to a DSM diagnosis and are often a secondary symptom to a primary medical problem.

In preparation for my new position, I have been reviewing many of my favorite references from school - Stahl, Carlat, Caplan. Most recently, I picked up the Massachusetts General Hospital Handbook of General Hospital Psychiatry. Since the bulk of my work will involve consultation in an emergent and acute-care setting, it is important to bone-up on all things psycho-somatic.  The book reviews essential skills  with a breakdown of assessment, diagnosis, and treatment by symptom and medical disease process. I particularly appreciate that while this is a physician-focused text, much of it is devoted to holistic assessment and communication, mindfulness, and follow-up beyond the initial evaluation and disposition. It also addresses ethics, legal considerations and collaboration issues, such as disagreement over diagnosis and interventions.  As with most Elsevier publications, you can activate the expert consult online, which includes a searchable text feature.  All that is missing is an integrated app!

Nurse Fight, Revisited.

At the 2010 APNA conference I was a newb to the plight of the Clinical Nurse Specialist phase-out. I listened, I empathized, and I agreed wholeheartedly that it was not fair. However, very little is fair in healthcare, and roles in all disciplines are continually merged, eliminated, grandfathered, or otherwise changed for the greater good of the consumer and the economy. Two years later I am hearing the same arguments resentments and resistance to continuing education and not a single course of action beyond "someone should do something."

Yes, the CNS role in mental health was there before the NP. While I profess enduring gratitude to these pioneers, being first is not a relevant reason for continuance of a role that is being incorporated into the now-dominant nurse practitioner certification. The psychotherapy skills at the core of CNS education are now part of most NP programs and total more hours than were required in the first CNS programs. This is particularly true for those pursuing the DNP. Individual future-NPs may be drawn to one aspect of practice than another, and can choose programs that fit their emphasis area of interest, but the core requirements set forth from the ANCC must be met, whether you want to write scripts all day, facilitate therapy, or lead process improvement projects. If you are in healthcare, you should be dedicated to life-long learning whether it is to maintain or update certification.  I am sure at some point, the American Board of Comprehensive Care exam - a ridiculously conceived and unvetted rip-off of the 3rd step of the USMLE -  will be required for certification or recertification in Family/Adult NP practice, at which time I will have to suck it up and take it (but not one second sooner than mandated, and I will be protesting it up to that second).


Yes, the CNS has paved the way for expansion in scope of practice by consistently providing cost-effective, outcome-driven, patient-centered care. Again, we would not be where we are today without these leaders, however, maintaining the high level of respectability and competence that has been cultivated comes from didactic and clinical education at the graduate (soon doctoral) level, and finding mentors in the first years of practice - the roles are not mutually exclusive. PMH providers are already thought of as the "not-a-real" arm of our parent disciplines, do we really want to separate ourselves further by advocating for two of the same with a different name? Are taking any of the 3Ps and sending off for a transcript really that professionally insulting? Could it not be viewed as an expanded practice update, just as our yearly CEU requirements are mandated? I went to a PMHNP/DNP program that was attended by CNSs who wanted to keep current. They did not have to retake clinical hours or classes, and their educational plans were tailored to their experiences. The money and time spent to convert from a CNS to a NP (with a DNP if you want to keep REALLY current) would provide all the necessary CEUs for state licensing or national credentialing and, depending on the program, cost less than a couple of national conferences.

Yes, the CNS in PMH is different than the CNS role is in other nursing specialties because of the emphasis on direct patient care rather than nursing education, organization, and leadership. The current roles of the NP and CNS in mental health have become increasingly redundant because we let it get that way. It is too late to go back in time and decide not to start PMH NP programs and restrict advanced PMH practice to the CNS designation, or to ensure the PMH CNS role stay in line with the CNS role in other advanced nursing specialties. It is ridiculous enough that advanced practice nursing is divided into four roles with six population foci (instead of one APRN designation with specialization - a soapbox for another time), but having 2 roles with the same foci is just sloppy. This is why the consensus model supported the retirement of other CNS specialties that overlap with NP practice (adult health, adult psych, child/ado psych, gerontology) and retirement or amendment of NP specialties that were too specific or did not include lifespan.

Yes, by supporting the APRN consensus model, the APNA did not advocate to keep the PMH CNS educational programs open throughout the country nor petition the ANCC to keep the certification exam active. I understand being upset at APNA for not advocating to keep the credential - every one of my mentors is now or started as a CNS - but the organization represents all psych nurses from vocational to doctoral degree. At any given time, some of the groups within the greater organization are going to feel their interests have been ignored. The APNA cannot dictate to profit-driven universities and certifying organizations how to conduct their business. The ANCC, who is responsible for administering, maintaining, and offering the certification, made the decision to discontinue the CNS designation, in part because universities have been phasing-out or incorporating CNS education into NP programs long before LACE. We can talk about how great CNS's are valued to patients, peers, and healthcare systems, but the hard truth here is the only argument that really matters is the economic argument. Frankly, I am shocked the AANP did not develop a limited-time bridge-exam for CNS-to-PMH just for the financial competition (tell me again why nursing has 2 certification bodies for advanced practice? Another soapbox for later). Universities and certification organizations are not making enough revenue to keep the PMH CNS viable. No money, no ticket.

Yes, nursing changes the rules more than other health discipline. Why? From entry to master, there are more people who call themselves "nurse" than any other health profession. We have to change to keep current and to define, grow, and protect our scope of practice. This often-labled "betrayal" of our own may be more common, but it is not at all unique to nursing. If one were to ask bachelors-prepared physical therapists, masters-prepared psychologists, pharmacologists without an MD or other doctoral healthcare degree, a masters prepared pharmacist before 1994, or MDs who find their primary practice certifications compartmentalized into new ABMS categories, they would empathize to varying degrees with what is happening to the CNS certification.  Doubtless there was and is outcry among our peer professional and some misunderstanding during the process, but I doubt most of them were calling shenanigans and recycling arguments years after the decision was made. I would like to think nurses, especially psych nurses, could figure out how to demonstrate resiliency and adaptation by finding ways to work the system to make the new system work for them.

For great background and perspective from someone involved in the development of the consensus model,  check out the LACE Dialogue for CNS blog by Dr. Kelly  Gourdreau, CNS.

APNA 26 Pre-Conference Presentation: Pushing the Point

Pushing the Point: Integrating Acupressure and Oriental Medicine in Psychiatric Nursing Care.

Pushing the Point: Integrating Acupressure & Oriental Medicine in Psychiatric Nursing from Jaclyn Engelsher, DNP

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