Psychiatric mental health nurse practitioner review and resource manual pdf

Semester Goals- "Feeling Paper"

Psychiatric Nurse Practitioner Program- goals could include mastering pharmacology and psychotherapy interventions

You are to write 4 pages double spaced scholarly paper focusing on evaluating your goals for this semester.
Please follow APA format, your paper should have a cover page, double spaced and utilize your course reading and Library resources for your evidence and References.
This journal is to state your goals for the semester based on reflection of the clinical experiences.
What are you learning and clinical goals?
How do you plan to achieve them?
Make them realistic and measurable.
Ethical and moral dilemmas may also be a part of your reflection and observations. This is a feeling assignment. Reflect on how you are feeling for this semester.
Conclusion.
Reference page

PSYCHIATRIC- MENTAL HEALTH NURSE PRACTITIONER 4th Edition

Nursing Certification Review Manual Continuing Education Resource Clinical Practice Resource

Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC

Dawn Vanderhoef, PhD, DNP, PMHNP-BC, PMHCNS-BC

Review and Resource Manual

P sychiatric-M

ental H ealth

N urse P

ractitio ner

R eview

and R

eso urce M

anual

4TH EDITION

PSYCHIATRIC-MENTAL HEALTH NURSE PRACTITIONER Review and Resource Manual, 4th Edition

Are you looking into how to advance your professional development through certification? Need a reliable and credible reference resource? No matter where you are in the process, make sure you have the most valuable review and resource tool at your disposal.

The Nursing Knowledge Center’s Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual is a must-have tool for nurses planning to take the American Nurses Credentialing Center’s (ANCC’s) Psychiatric-Mental Health Nurse Practitioner certification exam.

Based on the official ANCC certification exam test content outline, this review and resource manual will help you:

n Study and analyze comprehensive material and concepts written by nursing experts.

n Develop a recommended seven-step plan to equip you for the exam and map out what to do on the day of the exam.

n Prepare for and familiarize yourself with psychological-mental health practitioner standards of practice.

n And much more ...

Make the Psychiatric-Mental Health Nurse Practitioner Review

and Resource Manual a key resource in your certification preparation.

AMERICAN NURSES ASSOCIATION 8515 GEORGIA AVE., SUITE 400 SILVER SPRING, MD 20910-3492 1.800.284.2378 | 301.628.5000

©2016 American Nurses Association. All rights reserved. Nursing Knowledge Center is part of the American Nurses Association.

Completion of this or any other course(s)/material(s) does not imply eligibility for certification or successful performance on any certification examination, nor is it a requirement to qualify for certification. The American Nurses Credentialing Center (ANCC) does not endorse any products or services.

www.nursingknowledgecenter.org

Review and Resource Manual

Psychiatric– Mental Health Nurse Practitioner

NURSING KNOWLEDGE CENTER

CONTINUING EDUCATION SOURCE

NURSING CERTIFICATION REVIEW MANUAL

CLINICAL PRACTICE RESOURCE

4th Edition

Published by American Nurses Credentialing Center

Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC Dawn Vanderhoef, PhD, DNP, PMHNP-BC, PMHCNS-BC

Library of Congress Cataloging-in-Publication Data

Names: Johnson, Kathryn, 1947-, author. | Vanderhoef, Dawn, author. | Nursing Knowledge Center, publisher. Title: Psychiatric-mental health nurse practitioner review and resource manual / Kathryn Johnson, Dawn Vanderhoe. Other titles: Psychiatric-mental health nurse practitioner review manual Description: 4th edition. | Silver Spring, MD : Nursing Knowledge Center, American Nurses Association, 2016. | Preceded by Psychiatric-mental health nurse practitioner review manual / by Kathryn Johnson and Dawn Vanderhoef. 3rd edition. 2013. | Includes bibliographical references and index. Identifiers: LCCN 2016012871| ISBN 9781935213796 (pbk.) | ISBN 9781935213802 (ePub) | ISBN 9781935213819 (prc) | ISBN 9781935213826 (epdf) Subjects: | MESH: Psychiatric Nursing--methods | Education, Nursing, Continuing Classification: LCC RC438 | NLM WY 18.5 | DDC 616.89/0231--dc23 LC record available at http://lccn.loc.gov/2016012871

The American Nurses Association (ANA) is the only full-service professional organization representing the interests of the nation’s 3.1 million registered nurses through its constituent/ state nurses associations and its organizational affiliates. The ANA advances the nursing profession by fostering high standards of nursing practice, promoting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and lobbying the Congress and regulatory agencies on healthcare issues affecting nurses and the public.

© 2016 American Nurses Association 8515 Georgia Ave., Suite 400 Silver Spring, MD 20910 All rights reserved. Third printing, August 2018

i i i

CONTENTS

INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION CREDIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . XI

CHAPTER 1 . Taking The Certification Examination . . . . . . . . . . . . .1

General Suggestions for Preparing for the Exam 1

About the Certification Exams 8

Internet Resources 9

CHAPTER 2 . Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process . . . . . . . 11

Nurse Practitioner Advanced Practice Core Content 11

Nurse Practitioner Advanced Practice Specialized Content 12

History of the NP Role 13

Professional Role Responsibilities 16

Roles of the PMHNP 22

Culturally Competent Care and Special Populations 23

Case Study 1 29

Case Study 2 29

Answers to Case Study Discussion Questions 31

References and Resources 32

CHAPTER 3 . Theoretical Basis of Care . . . . . . . . . . . . . . . . . . . . . .37

Biopsychosocial Framework of Care 37

Classification of Psychiatric Disorders: DSM-5 38

iv CONTENTS

Therapeutic Relationship 38

Developmental Theories 40

Foundational Theories Supporting PMHNP Role 41

Nursing Theories 47

Case Study 1 48

Case Study 2 48

Answers to Case Study Discussion Questions 49

References and Resources 49

CHAPTER 4 . Psychiatric–Mental Health Nurse Practitioner Professional Role and Health Policy: Leadership, Quality Improvement and Safety, Practice Inquiry, and Health Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Leadership 51

Quality Improvement 55

Just Culture of Safety 55

Health Delivery Systems 56

Conflict of Interest 57

Rights of Clients 58

Health Policy Development 58

Case Study 59

Answers to Case Study Discussion Questions 60

References and Resources 60

CHAPTER 5 . Neuroanatomy, Neurophysiology, and Behavior . .63

The Nervous System 63

Neuroanatomy and the Brain 64

Neurophysiology and the Brain 68

Neuroimaging Assessment and Diagnostic Procedures 71

Genomics 73

vCONTENTS

Case Study 1 76

Case Study 2 76

Answers to Case Study Discussion Questions 77

References and Resources 77

CHAPTER 6 . Advanced Health and Physical Health Assessment . .79

Physical Exam 79

Neurological Exam 80

Disease Prevention Activities 97

Gender-Based Medical Testing and Screening Recommendations for the General Public 99

Health Behavior Guidelines 101

Public Health Principles 103

Case Study 1 105

Case Study 2 105

Answers to Case Study Discussion Questions 107

References and Resources 107

CHAPTER 7 . Pharmacological Principles . . . . . . . . . . . . . . . . . . . 111

Concepts in Pharmacological Management 111

PMHNP Pharmacological Management Role 114

Case Study 1 120

Case Study 2 120

Case Study 3 120

Answers to Case Study Discussion Questions 122

References and Resources 123

CHAPTER 8 . Nonpharmacological Treatment . . . . . . . . . . . . . . .125

Individual Therapy 125

Group Therapy 127

vi CONTENTS

Family Therapies 129

Complementary and Alternative Therapies (CATs) 132

Case Study 136

Answers to Case Study Discussion Questions 137

References and Resources 137

CHAPTER 9 . Depressive Disorders and Bipolar Disorders . . . . .139

Sadness as a Common Emotional State 139

Major Depressive Disorder (MDD) 140

Persistent Depressive Disorder (Dysthymia) 166

Grief and Bereavement 169

Premenstrual Dysphoric Disorder 173

Bipolar (BP) Disorder 173

Stevens Johnson Syndrome (SJS) 184

Cyclothymic Disorder 186

Case Study 189

Answers to Case Study Discussion Questions 191

References and Resources 191

CHAPTER 10 . Anxiety Disorders, Obsessive–Compulsive Disorder, and Trauma- and Stressor-Related Disorders . . . . .195

Anxiety Disorders 196

Panic Disorder 207

Agoraphobia 210

Specific Phobias (Simple Phobias) 211

Social Anxiety (Phobia) Disorder 214

Generalized Anxiety Disorder (GAD) 215

Separation Anxiety Disorder 218

Obsessive–Compulsive Disorder (OCD) 218

Posttraumatic Stress Disorder (PTSD) 222

viiCONTENTS

Dissociative Disorders 225

Body Dysmorphic Disorder 226

Hoarding Disorder 226

Trichotillomania 226

Excoriation Disorder 226

Case Study 227

Answers to Case Study Discussion Questions 230

References and Resources 230

CHAPTER 11 . Schizophrenia Spectrum and Other Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .233

General Description of Psychotic Disorders 233

Schizophrenia 235

Schizophreniform Disorder 258

Schizoaffective Disorder 260

Delusional Disorder 262

Brief Psychotic Disorder 264

Shared Psychotic Disorder (Folie á Deux) 266

Case Study 268

Answers to Case Study Discussion Questions 269

References and Resources 269

CHAPTER 12 . Neurocognitive Disorders . . . . . . . . . . . . . . . . . . . .271

Cognitive Disorders 271

Delirium 271

Dementia 277

Major or Minor Neurocognitive Disorder Due to Traumatic Brain Injury 285

Case Study 291

Answers to Case Study Discussion Questions 292

References and Resources 292

viii CONTENTS

CHAPTER 13 . Substance-Related and Addictive Disorders . . . . .293

Substance-Related Disorders 293

Case Study 308

Answers to Case Study Discussion Questions 310

References and Resources 310

CHAPTER 14 . Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . .313

Personality 313

Personality Disorders 314

Case Study 324

Answers to Case Study Discussion Questions 325

References and Resources 325

CHAPTER 15 . Disorders of Childhood and Adolescence . . . . . . .327

Assessment and Care Planning for Children and Adolescents 327

Oppositional Defiant Disorder (ODD) 329

Conduct Disorder 332

Attention-Deficit Hyperactivity Disorder (ADHD) 335

Autism Spectrum Disorder 340

Rett Syndrome 343

Eating Disorders 346

Intellectual Disability 351

Disruptive Mood dysRegulation Disorder 355

Case Study 357

Answers to Case Study Discussion Questions 358

References and Resources 358

CHAPTER 16 . Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .361

General Considerations 361

Insomnia 362

ixCONTENTS

Case Study 1 369

Case Study 2 369

Case Study 3 369

Answers to Case Study Discussion Questions 370

References and Resources 371

CHAPTER 17 . Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .373

Intimate Partner Violence (IPV) 373

Assessment 375

Sexual Assault and Abuse 376

Lethality Assessment 379

Violence in School 380

Suicide Assessment 380

Homicide: Early Warning Signs 381

Threats of Violence 381

Case Study 383

Answers to Case Study Discussion Questions 384

References and Resources 384

APPENDIX A . Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . .385

APPENDIX B . Review Question Answers . . . . . . . . . . . . . . . . . . . .409

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .417

xi

INSTRUCTIONS FOR OBTAINING CONTINUING EDUCATION CREDIT FOR STUDY OF THE PSYCHIATRIC–MENTAL HEALTH NURSE PRACTITIONER REVIEW AND RESOURCE MANUAL, 4TH EDITION The Nursing Knowledge Center offers continuing nursing education contact hours (CE) to those who review and study this manual and successfully complete an online module. To obtain CE credit you must purchase and review the manual, pay required fees to enroll in the online mod- ule, and complete all module components by the published CE expiration date including disclo- sures, pre- and posttests, and the course evaluation. The continuing nursing education contact hours online module can be completed at any time prior to the published CE expiration date and a certificate can be printed from the online learning management system immediately after suc- cessful completion of the online module. To purchase the online module for this manual visit the Nursing Knowledge Center’s online catalog at https://learn.ana-nursingknowledge.org/. Please contact online support with any questions about the CE or module.

Inquiries or Comments If you have any questions about the content of the manual please e-mail revmanuals@ana.org. You may also mail any comments to Editorial Project Manager at the address listed below.

Nursing Knowledge Center

Attn: Editorial Project Manager

8515 Georgia Avenue, Suite 400

Silver Spring, MD 20910-3492

Fax: (301) 628-5342

CE Provider Information ANA’s Center for Continuing Education and Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

ANCC Provider Number 0023.

ANA is approved by the California Board of Registered Nursing, Provider Number CEP6178.

Disclaimer Review and study of this manual and successful completion of the online module do not guaran- tee success on a certification examination. Purchase of this manual and completion of the online module are not required to obtain certification.

CHAPTER 1

TAKING THE CERTIFICATION EXAMINATION When you sign up to take a national certification exam, you will be instructed to go on- line and review the testing and review handbook (http://www.nursecredentialing.org/ GeneralTestingRenewalHandbook). Review it carefully and be sure to bookmark the site so you can refer to it frequently. It contains information on test content and sample questions. This is critical information; it will give you insight into the nature of the test. The agency will send you information about the test site; keep this in a safe place until needed.

GENERAL SUGGESTIONS FOR PREPARING FOR THE EXAM

Step One: Control Your Anxiety Everyone experiences anxiety when faced with taking the certification exam.

X Remember, your program was designed to prepare you to take this exam.

X Your instructors took a similar exam, and have probably talked to students who took exams more recently, so they know how to help you prepare.

X Taking a review course or setting up your own study plan will help you feel more confident about taking the exam.

Step Two: Do Not Listen to Gossip About the Exam A large volume of information exists about the tests based on reports from people who have taken the exams in the past. Because information from the testing facilities is limited, it is hard to ignore this gossip.

X Remember that gossip about the exam that you hear from others is not verifiable.

X Because this gossip is based on the imperfect memory of people in a stressful situa- tion, it may not be very accurate.

X People tend to remember those items testing content with which they are less com- fortable; for instance, those with a limited background in women’s health may say that the exam was “all women’s health.” In fact, the exam blueprint ensures that the exam covers multiple content areas without overemphasizing any one.

http://www.nursecredentialing.org/GeneralTestingRenewalHandbook
http://www.nursecredentialing.org/GeneralTestingRenewalHandbook
2 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

Step Three: Set Reasonable Expectations for Yourself X Do not expect to know everything.

X Do not try to know everything in great detail.

X You do not need a perfect score to pass the exam.

X The exam is designed for a beginner level—it is testing readiness for entry-level practice.

X Learn the general rules, not the exceptions.

X The most likely diagnoses will be on the exam, not questions on rare diseases or atypical cases.

X Think about the most likely presentation and most common therapy.

Step Four: Prepare Mentally and Physically X While you are getting ready to take the exam, take good physical care of yourself.

X Get plenty of sleep and exercise, and eat well while preparing for the exam.

X These things are especially important while you are studying and immediately before you take the exam.

Step Five: Access Current Knowledge

General Content

You will be given a list of general topics that will be on the exam when you register to take the exam. In addition, examine the table of contents of this book and the test content outline, avail- able at http://nursecredentialing.org/FamilyPsychMentalHealthNP.

X What content do you need to know?

X How well do you know these subjects?

Take a Review Course

X Taking a review course is an excellent way to assess your knowledge of the content that will be included in the exam.

X If you plan to take a review course, take it well before the exam so you will have plenty of time to master any areas of weakness the course uncovers.

X If you are prepared for the exam, you will not hear anything new in the course. You will be familiar with everything that is taught.

X If some topics in the review course are new to you, concentrate on these in your studies.

X People have a tendency to study what they know; it is rewarding to study some- thing and feel a mastery of it! Unfortunately, this will not help you master unfamiliar content. Be sure to use a review course to identify your areas of strength and weak- ness, then concentrate on the weaknesses.

http://nursecredentialing.org/FamilyPsychMentalHealthNP
3taking the certification exaMination

Depth of Knowledge

How much do you need to know about a subject?

X You cannot know everything about a topic.

X Remember that the depth of knowledge required to pass the exam is for entry-level performance.

X Study the information sent to you from the testing agency, what you were taught in school, what is covered in this text, and the general guidelines given in this chapter.

X Look at practice tests designed for the exam. Practice tests for other exams will not be helpful.

X Consult your class notes or clinical diagnosis and management textbook for the ma- jor points about a disease. Additional reference books can be found online at http:// nursecredentialing.org/PsychNP-TestReferenceList.

X For example, with regard to medications, know the drug categories and the major medications in each. Assume all drugs in a category are generally alike, and then fo- cus on the differences among common drugs. Know the most important indications, contraindications, and side effects. Emphasize safety. The questions usually do not require you to know the exact dosage of a drug.

Step Six: Institute a Systematic Study Plan

Develop Your Study Plan

X Write up a formal plan of study.

Z Include topics for study, timetable, resources, and methods of study that work for you.

Z Decide whether you want to organize a study group or work alone.

Z Schedule regular times to study.

Z Avoid cramming; it is counterproductive. Try to schedule your study periods in 1-hour increments.

X Identify resources to use for studying. To prepare for the examination, you should have the following materials on your shelf:

Z A good pathophysiology text.

Z This review book.

Z A physical assessment text.

Z Your class notes.

Z Other important sources, including: information from the testing facility, a clinical diagnosis textbook, favorite journal articles, notes from a review course, and practice tests.

Z Know the important national standards of care for major illnesses.

Z Consult the bibliography on the test blueprint. When studying less familiar material, it is helpful to study using the same references that the testing center uses.

X Study the body systems from head to toe.

http://nursecredentialing.org/PsychNP-TestReferenceList
http://nursecredentialing.org/PsychNP-TestReferenceList
4 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

X The exams emphasize health promotion, assessment, differential diagnosis, and plan of care for common problems.

X You will need to know facts and be able to interpret and analyze this information utilizing critical thinking.

Personalize Your Study Plan

X How do you learn best?

Z If you learn best by listening or talking, attend a review course or discuss topics with a colleague.

X Read everything the test facility sends you as soon as you receive it and several times during your preparation period. It will give you valuable information to help guide your study.

X Have a specific place with good lighting set aside for studying. Find a quiet place with no distractions. Assemble your study materials.

Implement Your Study Plan

You must have basic content knowledge. In addition, you must be able to use this information to think critically and make decisions based on facts.

X Refer to your study plan regularly.

X Stick to your schedule.

X Take breaks when you get tired.

X If you start procrastinating, get help from a friend or reorganize your study plan.

X It is not necessary to follow your plan rigidly. Adjust as you learn where you need to spend more time.

X Memorize the basics of the content areas you will be required to know.

Focus on General Material

X Most of what you need to know is basic material that does not require constant updating.

X You do not need to worry about the latest information being published as you are studying for the exam. Remember, it can take 6 to 12 months for new information to be incorporated into test questions.

Pace Your Studying

X Stop studying for the examination when you are starting to feel overwhelmed and look at what is bothering you. Then make changes.

X Break overwhelming tasks into smaller tasks that you know you can do.

X Stop and take breaks while studying.

Work With Others

X Talk with classmates about your preparation for the exam.

X Keep in touch with classmates, and help each other stick to your study plans.

5taking the certification exaMination

X If your classmates become anxious, do not let their anxiety affect you. Walk away if you need to.

X Do not believe bad stories you hear about other people’s experiences with previous exams.

X Remember, you know as much as anyone about what will be on the next exam!

Consider a Study Group

X Study groups can provide practice in analyzing cases, interpreting questions, and critical thinking.

X You can discuss a topic and take turns presenting cases for the group to analyze.

X Study groups can also provide moral support and help you continue studying.

Step Seven: Strategies Immediately Before the Exam

Final Preparation Suggestions

X Use practice exams when studying to get accustomed to the exam format and time restrictions.

Z Many books that are labeled as review books are simply a collection of examination questions.

Z If you have test anxiety, such practice tests may help alleviate the anxiety.

Z Practice tests can help you learn to judge the time it should take you to complete the exam.

Z Practice tests are useful for gaining experience in analyzing questions.

Z Books of questions may not uncover the gaps in your knowledge that a more systematic content review text will reveal.

Z If you feel that you don’t know enough about a topic, refer to a text to learn more. After you feel that you have learned the topic, practice questions are a wonderful tool to help improve your test-taking skill.

X Know your test-taking style.

Z Do you rush through the exam without reading the questions thoroughly?

Z Do you get stuck and dwell on a question for a long time?

Z You should spend about 45 to 60 seconds per question and finish with time to review the questions you were not sure about.

Z Be sure to read the question completely, including all four answer choices. Choice “a” may be good, but “d” may be best.

The Night Before the Exam

X Be prepared to get to the exam on time.

Z Know the test site location and how long it takes to get there.

Z Take a “dry run” beforehand to make sure you know how to get to the testing site, if necessary.

6 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

Z Get a good night’s sleep.

Z Eat sensibly.

Z Avoid alcohol the night before.

Z Assemble the required material—two forms of identification, admission card, pencil, and watch. Both IDs must match the name on the application, and one photo ID is preferred.

Z Know the exam room rules.

X You will be given scratch paper, which will be collected at the end of the exam.

X Nothing else is allowed in the exam room.

X You will be required to put papers, backpacks, etc., in a corner of the room or in a locker.

X No water or food will be allowed.

X You will be allowed to walk to a water fountain and go to the bathroom one at a time.

The Day of the Exam

X Get there early. You must arrive to the test center at least 15 minutes before your scheduled appointment time. If you are late, you may not be admitted.

X Think positively. You have studied hard and are well-prepared.

X Remember your anxiety reduction strategies.

Specific Tips for Dealing With Anxiety

Test anxiety is a specific type of anxiety. Symptoms include upset stomach, sweaty palms, tachycardia, trouble concentrating, and a feeling of dread. But there are ways to cope with test anxiety.

X There is no substitute for being well-prepared.

X Practice relaxation techniques.

X Avoid alcohol, excess coffee, caffeine, and any new medications that might sedate you, dull your senses, or make you feel agitated.

X Take a few deep breaths and concentrate on the task at hand.

Focus on Specific Test-Taking Skills

To do well on the exam, you need good test-taking skills in addition to knowledge of the content and ability to use critical thinking.

All Certification Exams Are Multiple Choice X Multiple-choice tests have specific rules for test construction.

X A multiple-choice question consists of three parts: the information (or stem), the question, and the four possible answers (one correct and three distracters).

7taking the certification exaMination

X Careful analysis of each part is necessary. Read the entire question before answering.

X Practice your test-taking skills by analyzing the practice questions in this book and on the ANCC website.

Analyze the Information Given

X Do not assume you have more information than is given.

X Do not overanalyze.

X Remember, the writer of the question assumes this is all of the information needed to answer the question.

X If information is not given, it is not relevant and will not affect the answer.

X Do not make the question more complicated than it is.

What Kind of Question Is Asked?

X Are you supposed to recall a fact, apply facts to a situation, or understand and dif- ferentiate between options?

Z Read the question thinking about what the writer is asking.

Z Look for key words or phrases that lead you (see Figure 1 –1). These help determine what kind of answer the question requires.

Read All of the Answers

X If you are absolutely certain that answer “a” is correct as you read it, mark it, but read the rest of the question so you do not trick yourself into missing a better answer.

X If you are absolutely sure answer “a” is wrong, cross it off or make a note on your scratch paper and continue reading the question.

X After reading the entire question, go back, analyze the question, and select the best answer.

X Do not jump ahead.

X If the question asks you for an assessment, the best answer will be an assessment. Do not be distracted by an intervention that sounds appropriate.

X If the question asks you for an intervention, do not answer with an assessment.

avoid

best

except

not

initial

first

contributing to

appropriate

most

significant

likely

of the following

most consistent with

FIGURE 1–1 . EXAMPLES OF KEY WORDS AND PHRASES

8 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

X When two answer choices sound very good, the best one is usually the least ex- pensive, least invasive way to achieve the goal. For example, if your answer choices include a physical exam maneuver or imaging, the physical exam maneuver is prob- ably the better choice provided it will give the information needed.

X If the answers include two options that are the opposite of each other, one of the two is probably the correct answer.

X When numeric answers cover a wide range, a number in the middle is more likely to be correct.

X Watch out for distracters that are correct but do not answer the question, combine true and false information, or contain a word or phrase that is similar to the correct answer.

X Err on the side of caution .

Only One Answer Can Be Correct

X When more than one suggested answer is correct, you must identify the one that best answers the question asked.

X If you cannot choose between two answers, you have a 50% chance of getting it right if you guess.

Avoid Changing Answers

X Change an answer only if you have a compelling reason, such as you remembered something additional, or you understand the question better after rereading it.

X People change to a wrong answer more often than to a right answer.

Time Yourself to Complete the Whole Exam

X Do not spend a large amount of time on one question.

X If you cannot answer a question quickly, mark it and continue the exam.

X If time is left at the end, return to the difficult questions.

X Make educated guesses by eliminating the obviously wrong answers and choosing a likely answer even if you are not certain.

X Trust your instinct.

X Answer every question. There is no penalty for a wrong answer.

X Occasionally a question will remind you of something that helps you with a question earlier in the test. Look back at that question to see if what you are remembering affects how you would answer that question.

ABOUT THE CERTIFICATION EXAMS

The American Nurses Credentialing Center Computerized Exam

The ANCC examination is given only as a computer exam, and each exam is different.

The order of the questions is scrambled for every test, so even if two people are taking the same exam, the questions will be in a different order. The exam consists of 175 multiple-choice questions.

9taking the certification exaMination

X 150 of the 175 questions are part of the test and how you answer will count toward your score; 25 are included to refine questions and will not be scored. You will not know which ones count, so treat all questions the same.

X You will need to know how to use a mouse, scroll by either clicking arrows on the scroll bar or using the up and down arrow keys, and perform other basic computer tasks.

X The exam does not require computer expertise.

X However, if you are not comfortable with using a computer, you should practice us- ing a mouse and computer beforehand so you do not waste time on the mechanics of using the computer.

Know what to expect during the test.

X Each ANCC test question is independent of the other questions.

Z For each case study, there is only one question. This means that a correct answer on any question does not depend on the correct answer to any other question.

Z Each question has four possible answers. There are no questions asking for combinations of correct answers (such as “a and c”) or multiple-multiples.

X You can skip a question and go back to it at the end of the exam.

X You cannot mark key words in the question or right or wrong answers. If you want to do this, use the scratch paper.

X You will get your results immediately, and a grade report will be provided upon leav- ing the testing site.

INTERNET RESOURCES X ANCC website: www.nursecredentialing.org

X ANA bookstore: www.nursesbooks.org. Catalog of ANA nursing scope and stan- dards publications and other titles that may be listed on your test content outline

X National Guideline Clearinghouse: www.ngc.gov

http://www.nursecredentialing.org
http://www.nursesbooks.org
http://www.ngc.gov
CHAPTER 2

PSYCHIATRIC–MENTAL HEALTH NURSE PRACTITIONER ROLE, SCOPE OF PRACTICE, AND REGULATORY PROCESS Starting in the 1950s with the seminal work of two psychiatric nurses, June Mellow (1968) and Hildegard Peplau (1952), psychiatric nursing has been a well-established, well-recognized sub- specialty of nursing. The emergence of the psychiatric–mental health nurse practitioner (PMHNP) role reflects the growth of the advanced practice role, the acceptance of a brain-based etiology of psychiatric disorders, and an awareness of the need to provide holistic nursing care that does not artificially separate mind and body (Stuart, 2013).

The PMHNP role is built on fundamental, core advanced practice knowledge common to all nurse practitioners. This base of knowledge is expanded to include the very specific knowledge of the subspecialty of psychiatry. This chapter reviews the role of the PMHNP, the scope of prac- tice, and the regulatory process.

Advanced practice nurses specializing in psychiatry are educationally prepared at the master’s or doctoral level, possess in-depth knowledge and skills in the specialty area, and provide pri- mary psychiatric care to individuals or families at risk for or currently experiencing a psychiatric disorder.

NURSE PRACTITIONER ADVANCED PRACTICE CORE CONTENT All nurse practitioners upon graduation are expected to meet a set of core competencies (National Organization of Nurse Practitioner Faculties [NONPF], 2014). Specialty competencies, such as the Psychiatric–Mental Health Nurse Practitioner Competencies, are then built upon these core competencies (NONPF, 2013).

Nurse Practitioner Core Competencies X Scientific Foundations

X Leadership

X Quality

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X Practice Inquiry

X Technology and Information Literacy

X Policy

X Health Delivery System

X Ethics

X Independent Practice

NURSE PRACTITIONER ADVANCED PRACTICE SPECIALIZED CONTENT The specialty competencies are specifically designed for entry-level psychiatric–mental health nurse practitioners. These specialty competencies are to be used with the Nurse Practitioner (NP) Core Competencies. The specialty competencies address the life-span PMHNP focus, in- cluding families and populations. As changes occur within the healthcare system, these compe- tencies will also change (NONPF, 2013).

Leadership Competencies

X Participates in community and population-focused programs that evaluate programs and promote mental health and prevent or reduce risk of mental health problems

X Advocates for complex client and family medicolegal rights and issues

X Collaborates with interprofessional colleagues about advocacy, policy to reduce health disparities and improve outcomes for populations

Quality Competencies

X Evaluates the appropriate uses of seclusion and restraints in the care process

Policy Competencies

X Employs opportunities to influence health policy to reduce the impact of stigma on services for prevention and treatment of mental health problems and psychiatric disorders

Independent Practice Competencies

X Develops age-appropriate treatment plans

X Includes differential diagnosis

X Assesses impact of acute and chronic medical problems on psychiatric treatment

X Conducts individual and group psychotherapy

X Applies supportive psychodynamic, cognitive, behavioral, and other evidence-based psychotherapies to brief and long-term practice

X Applies recovery-oriented principles

X Demonstrates best practices of family care approaches

X Plans care to minimize the development of complications and promote function

X Treats acute and chronic psychiatric disorders and problems

13Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

X Safely prescribes pharmacologic agents

X Ensures client safety through the appropriate prescription of pharmacologic and nonpharmacologic interventions

X Explains the risks and benefits of treatment to client and family

X Identifies the role of PMHNP in risk mitigation strategies in areas of opiate use and substance abuse

X Seeks consultation

X Uses self-reflection to improve care

X Provides consultation to healthcare providers and others to enhance quality and cost

X Guides the client in evaluating the appropriate use of complementary and alternative treatment

X Uses individualized outcome measure to evaluate psychiatric care

X Manages psychiatric emergencies

X Refers clients appropriately

X Facilitates the transition of clients across levels of care

X Uses outcomes to evaluate care

X Attends to the client–NP relationship as a vehicle for change

X Maintains a therapeutic relationship over time with individuals and groups

X Therapeutically concludes the client–NP relationship

X Demonstrates ability to address sexual and physical abuse, substance abuse, sexual- ity, and spiritual conflicts

X Applies therapeutic relationship strategies based on theory and research

X Applies principles of self-efficacy, empowerment, and others to effect change

X Identifies and maintains professional boundaries

X Teaches clients, families, and groups

X Provides psychoeducation

X Modifies the treatment approach based on client readiness

X Considers motivation and readiness to improve self-care

X Demonstrates knowledge of appropriate use of seclusion and restraint

X Documents appropriate use of seclusion and restraint

HISTORY OF THE NP ROLE The NP role was introduced in 1965 by Loretta C. Ford, EdD, and Henry K. Silver, MD, at the University of Colorado (Mirr Jansen & Zwygart-Stauffacher, 2006). They identified new roles in which experienced registered nurses (RNs) with advanced education and skills were perform- ing clinical duties traditionally reserved for physicians. Universities were slow to implement NP programs at the master’s level. However, RNs embraced the new role and rushed into continuing education programs of varying length, quality, and focus to accomplish the necessary educa- tional preparation for this new role.

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In 2008 the License, Accreditation, Certification, and Education (LACE) consensus model was finalized and adopted by many nursing organizations. The consensus model identified four Advanced Practice Registered Nurse roles: Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), and Certified Nurse Practitioner (CNP). As part of the LACE model, Psychiatric–Mental Health was identified as a population fo- cus. The American Psychiatric Nurses Association (APNA) and International Society of Psychiatric Nurses (ISPN) recommendation was for psychiatric–mental health nurse practitioners (PMHNPs) to be prepared across the life span (APNA, 2011). As of 2015 APRNs in psychiatric–mental health nursing have one certification examination, PMHNP–Life Span, with the American Nurses Credentialing Center (ANCC, 2015). All previous psychiatric–mental health advanced practice certification examinations have been retired as of December 2015 (ANCC, 2015).

Proven competence brought an acceptance of the NP role in the healthcare system, with ac- ceptance and recognition of the title and role by consumers and other health professionals. NP programs are accredited by one of two organizations to achieve standardization and control over quality: the Commission on Collegiate Nursing Education (CCNE, 2016) and the Accreditation Commission for Education in Nursing (ACEN, 2016). NPs are recognized providers under many third-party insurance coverage plans (e.g., Medicare, Medicaid, CHAMPUS, federal programs funding school-based clinics, U.S. military, Veterans Administration).

Growth of the NP Role X Facilitating factors for growth

Z Consumer demand for services

Z Acceptance of the advanced practice nursing role

Z Emergence of the PMHNP role

Z Decreasing stigmatization

Z Emphasis on integrated healthcare services

X Constraining factors for growth

Z Growing competition in job market in general for NPs

Z Reimbursement struggles with Medicare and private insurance companies

Z Overlapping scope of practice with other NPs

Z Increased concerns over reimbursement fraud and abuse (e.g., issues of coding and billing for services)

Z Scope of practice and need for formal supervisory or collaborative relationships with physicians

Regulatory and Statutory Dimensions of the NP Role X State legislative statutes

Z Grant legal authority for NP practice

Z The Nurse Practice Act of every state

X Provides title protection (who may be called a nurse practitioner)

X Defines advanced practice

15Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

X Prevailing state laws that define scope of practice (what NPs may do)

X Places restrictions on practice

X Sets NP credentialing requirements (e.g., educational requirements, certification)

X States grounds for disciplinary action:

Z Practicing without valid license

Z Falsification of records

Z Medicare fraud

Z Failure to use appropriate nursing judgment

Z Failure to follow accepted nursing standards

Z Failure to complete accurate nursing documentation

X May specifically require that an NP develop a collaborative agreement with a physician

Z Collaborative agreement: Also known as a protocol that describes what types of drugs might be prescribed and defines some form of oversight for NP practice

X Statutory law

Z Rules and regulations differ for each state

Z May further define scope of practice and practice requirements

Z May provide restrictions in practice unique to specific state

X Licensure

Z A process by which an agency of state government grants permission to persons to engage in the practice of that profession

Z Also prohibits all others from legally doing protected practice

X Credentialing

Z Process used to protect the public by ensuring a minimum level of professional competence

X Certification

Z A credential that provides title protection

Z Determines scope of practice (i.e., whom NPs can see and what NPs can treat)

Z The process by which a professional organization or association certifies that a person licensed to practice as a professional has met certain predetermined standards specified by that profession for specialty practice

Z Assures the public that a person has mastery of a specified body of knowledge

Z Assures that the person has acquired the skills necessary to function in a particular specialty

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Z The American Nurses Credentialing Center (ANCC), which is a subsidiary of the American Nurses Association, is the only certifying body for advanced practice psychiatric nursing.

X Certification offered as a Psychiatric–Mental Health Nurse Practitioner–Life Span (ANCC, 2015)

X Scope of practice

Z Defines NP roles and actions

Z Identifies competencies assumed to be held by all NPs who function in a particular role

Z Varies broadly from state to state

Z Advanced practice PMHNP standards are identified in Psychiatric-Mental Health Nursing: Scope and Standards of Practice (ANA, 2014).

X Standards of practice

Z Authoritative statements regarding the quality and type of practice that should be provided

Z Provide a way to judge the nature of care provided

Z Reflect the expectation for the care that should be provided to clients with various illnesses

Z Reflect professional agreement focused on the minimum levels of acceptable performance

Z Can be used to legally describe the standard of care that must be met by a provider

Z May be precise protocols that must be followed or more general guidelines that recommend actions

PROFESSIONAL ROLE RESPONSIBILITIES X Confidentiality

Z The client’s right to assume that information given to the healthcare provider will not be disclosed

Z Protected under federal statute through the Medical Record Confidentiality Act of 1995 (S. 1360)

Z Pertains to verbal and written client information

Z Requires that the provider discuss confidentiality issues with clients, establish consent, and clarify any questions about disclosure of information

Z Requires that provider obtain a signed medical authorization and consent form to release medical records and information when requested by the client or another healthcare provider

X HIPAA

Z The first national comprehensive privacy protection act

Z Guarantees clients four fundamental rights:

17Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

1. To be educated about HIPAA privacy protection,

2. To have access to their own medical records,

3. To request amendment of their health information to which they object, and

4. To require their permission for disclosure of their personal information.

X The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 (Health Resources and Services Administration [HRSA], 2013)

Z Incentive payments for sharing specific electronic health record (EHR) data

Z Meaningful use incentives

Z Electronic health records can improve both individual and population-based health outcomes (Friedman, Parrish, & Ross, 2013).

Z Electronic health records can improve quality, safety, efficiency, effectiveness, and outcomes (U.S. DHHS, Office for Civil Rights, 2013).

X E-prescribing

X Computerized physician order sets

X Tracking care and avoiding duplication of services

X Telehealth

Z The use of telephone or videoconferencing tools to deliver mental health care to clients who reside in rural areas or who may otherwise not be able to access care

Z Must follow the same standards as care delivered in person

Z Must be practiced in accordance with international, federal, and state regulatory agency standards

Z Must include provisions for emergency care of the client

Z The PMHNP must assure that HIPAA regulations regarding confidentiality and maintenance of the health record are followed.

X Exceptions to guaranteed confidentiality

Z When appropriate persons or organizations determine that the need for information outweighs the principle of confidentiality

Z If a client reveals an intent to harm self or others

Z Information given to attorneys involved in litigation

Z Releasing records to insurance companies

Z Answering court orders, subpoenas, or summonses

Z Meeting state requirements for mandatory reporting of diseases or conditions

Z Tarasoff principle (Tarasoff v. Regents at the University of California, 1976): Duty to warn potential victim of imminent danger of homicidal clients

Z In cases of child or elder abuse

X Informed consent

Z The communication process between the provider and the client that results in the client’s acceptance or rejection of the proposed treatment

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Z An explanation of relevant information that enables the client to make an appropriate and informed decision

Z The right of all competent adults or emancipated minors

X Emancipated minors: Persons younger than 18 years old who are married, parents, or self-sufficiently living away from the family domicile

Z Elements of informed consent

X Nature and purpose of proposed treatment or procedure

X Risks or discomforts and benefits of treatment

X Risks and benefits of not undergoing treatment

X Alternative procedures or treatments

X Diagnosis and prognosis

Z Provider must document in the medical record that informed consent has been obtained from the client.

Z PMHNP is responsible for ensuring that the client is cognitively capable of giving informed consent.

X Ethics

Z Important aspect of the NP role that deals with moral duties, obligations, and responsibilities

Z What is right versus what is wrong

Z Ethical principles that provide foundation and direction for complex decisions:

X Justice: Doing what is fair; fairness in all aspects of care

X Beneficence: Promoting well-being and doing good

X Nonmaleficence: Doing no harm

X Fidelity: Being true and loyal

X Autonomy: Doing for self

X Veracity: Telling the truth

X Respect: Treating everyone with equal respect

Z In 2015 the American Nurses Association (ANA) published the Code of Ethics for Nurses with Interpretive Statements (ANA, 2015). Its nine provisions are:

1. The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of everyone.

2. The nurse’s primary commitment is to the client, whether an individual, family, group, community, or population.

3. The nurse promotes, advocates for, and protects the rights, health, and safety of the client.

4. The nurse has the authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to promote health and provide optimal care.

19Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

5. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

6. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.

7. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

8. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

9. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Z Important ethical principles in psychiatry

X Clients must be involved in decision-making to the full extent of their capacity (mutual decision-making).

X Clients have a right to treatment in the least restrictive setting.

X Clients have a right to refuse treatment unless a legal process resulting in a mandatory court order for treatment has been obtained.

Z Ethical dilemma

X Occurs in a situation in which there are two or more justifiable alternatives

X Occurs when the choice is made to promote good

X Which option sacrifices the fewest high-priority values (a harm reduction approach)?

Z Theoretical approaches to ethical decision-making

X Deontological Theory: An action is judged as good or bad based on the act itself regardless of the consequences.

X Teleological Theory: An action is judged as good or bad based on the consequence or outcome.

X Virtue Ethics: Actions are chosen based on the moral virtues (e.g., honesty, courage, compassion, wisdom, gratitude, self-respect) or the character of the person making the decision.

Ethics of Disclosure by Providers X Clients have a right to know what is happening during the course of their treatment.

X Providers have an ethical responsibility to disclose medical errors, accidents, injuries, and negative results to clients.

X As a result of the disclosure, a client may have legal right to compensation for harm suffered due to medical misadventures (Sadock, Sadock, & Ruiz, 2015).

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Risk vs . Benefits of Disclosure of Disability Regarding Employment X The Americans with Disabilities Act (ADA) works to prevent discrimination by

employers with 15 or more employees against qualified persons in hiring, firing, advancement, job training, compensation, and workplace conditions (Buppert, 2012).

X The ADA is federal legislation granting Americans who have disabilities, includ- ing mental illness, the opportunity for employment on an equal basis with the nondisabled.

X Employers are required to make reasonable accommodations for qualified applicants or employees with a disability.

Risk of Disclosure

X Employers may find ways to avoid hiring persons known to have a disability.

X Coworkers may harass or discriminate against persons with psychiatric illnesses.

X Assumption that persons with psychiatric illnesses may be less productive

X May limit an employee’s chance for advancement in career

X Feedback for improvement may not be given to employee because others may at- tribute the employee’s behavior to the psychiatric illness.

X Labeling oneself as “disabled” may affect one’s beliefs or self-image.

Benefits of Disclosure

X Able to request reasonable accommodations

X Opportunity to have a job coach come to the worksite and communicate directly with employer

X Employee can involve an employment service provider, employee assistance pro- gram, or other third party in the development of accommodations.

X Easier for employee to come to work during an exacerbation of symptoms

X May help with the recovery process

X Allows coworkers to offer personal support

X May empower another employee to disclose

Legal Considerations X Malpractice insurance

Z Provides financial protection against claims of malpractice

X Coverage for negligent professional acts

X Coverage for highly technical or professional skills required by health professionals, including NPs

Z Recommended universally for all NPs

Z Does not protect NPs from charges of practicing outside their legal scope of practice

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Z Provides NPs their own legal representation to advocate for them even if their agency also carries malpractice liability insurance protection

Z Four elements of negligence that must be established to prove malpractice:

1. Duty: The NP had a duty to exercise reasonable care when undertaking and providing treatment to the client.

2. Breach of duty: The NP violated the applicable standard of care in treating the client’s condition.

3. Proximate cause: There is a causal relationship between the breach in the standard of care and the client’s injuries.

4. Damages: The client experiences permanent and substantial damages as a result of the breach in the standard of care.

Competency X A legal, not a medical concept

X A determination that a client can make reasonable judgments and decisions regard- ing treatment and other health concerns

X A person is considered competent until a court rules the person to be incompetent.

X If a person is deemed incompetent, a court-appointed guardian will make health- related decisions for that person.

Commitment X Process of forcing a person to receive involuntarily evaluation or treatment

X Process may differ from state to state

X Basic criteria include

Z Person has a diagnosed psychiatric disorder,

Z Person is harmful to self or others as a consequence of the disorder,

Z Person is unaware or unwilling to accept the nature and severity of the disorder, and

Z Treatment is likely to improve functioning.

X Involuntary admission

Z Admission to a hospital or other treatment facility against the person’s will

Z Clients maintain all civil liberties except the ability to come and go as they please

Z Amount of time clients can be kept against their wishes varies by state

X Voluntary admission

Z Admission to a hospital or other treatment facility that a person desires or agrees to

Z Client maintains all civil liberties

Z Client consents to potential confinement within the structure of a hospital setting

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ROLES OF THE PMHNP

Scholarly Activities X It is important for NPs to engage in the following scholarly activities:

Z Publishing

Z Lecturing or presenting

Z Preceptorship

Z Continuing education

Mentoring X A process in which a more experienced NP agrees to guide and support a junior col-

league in the role, competencies, and skills

X Requires mutual respect and an interactive process of learning

X Needs involvement by both the mentor and the mentee in the relationship

Client Advocacy X Stand up for clients’ rights and empower them to become their own advocates

X Reduce the stigma of mental illness

X Help clients receive available services

X Promote mental health by participating in one or more of these professional organizations:

Z American Nurses Association (ANA)

Z American Psychiatric Nurses Association (APNA)

Z International Society of Psychiatric Nurses (ISPN)

Health Policy X Advanced practice nurses have a legal and ethical responsibility to be a client

advocate.

Z Participation in local, state, national, and international health policy activities (Buppert, 2012)

Z Involvement: Testify at a public meeting, lobby, or work with the media to bring awareness to an issue

Z Phases of policy-making: formulation, implementation, and evaluation (Abood, 2007)

Case Management X A system of controlled oversight and authorization of services and benefits provided

to clients

23Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

X Consists of coordinating care, ensuring quality outcomes, monitoring plan of care, and doing advocacy

X Overall goal is to promote quality, cost-effective outcomes

Risk Assessment

X Continuous monitoring for high-risk situations

X Assessing persons for nonhealthy behaviors

Risk Management

X Activities or systems designed to recognize and intervene to reduce the risk of injury to clients

X Appropriate interventions implemented to reduce nonhealthy behaviors in clients and high-risk situations

X Recognition and intervention to reduce subsequent claims against healthcare providers

Advance Directives X Durable power of attorney for health care. Also known as healthcare proxy

Z Legally binding in all 50 states

Z Designates, in writing, an agent to act on behalf of a person should he or she become unable to make healthcare decisions

Z Not limited to terminal illness; also covers other aspects of illness, such as making financial decisions during a person’s illness

Z Should be considered as an aspect of relapse planning for clients with chronic psychiatric disorders

X Living will: Document prepared while client is mentally competent to designate preferences for care if client becomes incompetent or terminally ill

Z Not legally binding in all states

CULTURALLY COMPETENT CARE AND SPECIAL POPULATIONS X Treating clients from diverse cultures, viewing each client as a unique person, and

noting a potential relationship between clients’ cultural experiences and their symp- tom presentation and perceptions

X Assumes that if the NP becomes more sensitive to cultural issues influencing the client’s symptoms and treatment, more comprehensive health care can be provided

X Culture: The learned beliefs and behaviors or the socially inherited characteristics that are common among all members of a group; may be a racial, social, ethnic, or religious grouping

X Culture-bound syndromes: Specific behaviors related to a person’s culture and not linked to a psychiatric disorder

Z Be cognizant of inaccurately judging a client’s behavior as psychopathology when it is really related to his or her culture.

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Cultural Influences and Determinants of Health

X Family: A group of adults and children who are usually related and whose adults participate in carrying out the essential functions of providing food, clothing, shelter, safety, and education of children

Z Concept broadened beyond the traditional husband–wife–children pattern

Z Family initially teaches the belief patterns, religion, culture, and mores of a society.

X Ethnicity: Self-identified race, tribe, or nation with which a person or group identifies and which greatly influences beliefs and behavior

X Community: A group of families, often sharing the same race, tribe, or culture, who have beliefs or behavior not shared by others

X Environment: Includes both physical and psychosocial factors; the general circum- stances of a person’s life:

Z Social contacts

Z Housing surroundings

Z Climate

Z Altitude

Z Temperature

Z Air pollution

Z Fluoride in water

Z Water contamination

Z Crime

Z Poverty

Z Transportation

Homelessness Homelessness is an enormous problem affecting the United States and the world. It can have devastating effects on individuals’ and families’ emotional and physical health. Drugs, alco- hol, violence, and behavioral problems are just a few major issues faced by persons who are homeless. The practitioner must be aware of the challenges faced by this vulnerable popula- tion. Possessing appropriate communication skills and knowledge of available resources are invaluable.

X Homeless person

Z Someone who does not have stable or consistent nighttime housing or who maintains permanent residence at shelters, hotels, transitional housing, or public places not appropriate for human beings to live in; someone intended to be institutionalized who is in an institution for transitory residence

Z Men, women, and children make up the homeless population. The number of homeless families is on the rise.

X The majority of homeless families are headed by a single parent, usually a woman.

Z Female-headed households are at high risk for becoming homeless if the head of household has limited education or employment skills, low-paying employment with little or no benefits, and limited access to affordable housing.

Z Teen mothers are at high risk due to lack of education and incomes that older parents possess.

25Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

Z Reasons for homelessness:

X Mental illness

X Addictive disorders

X Poverty

X Unemployment

X Inadequate public assistance

X Domestic violence

X Lifestyle choice

X Mental illness and addictive disorders in the homeless population:

Z Approximately 50% of homeless people have co-occurring substance use disorders and serious mental illness, including bipolar disorder, schizophrenia, and depression.

Z Schizophrenia accounts for 15% to 45% of the U.S. homeless population (Sadock, Sadock, & Ruiz, 2015).

Z Symptoms are often active and untreated.

Z Untreated serious mental illness results in symptoms such as paranoia, hallucinations, mania, anxiety, and depression, making it difficult for people to maintain employment, relationships, and other activities of daily living.

Z Homeless people with co-occurring disorders are at a greater risk for violence, medication noncompliance, and treatment resistance.

Strategies for Reducing Homelessness

X Outreach: Introducing services to homeless persons with serious mental illness in various settings, building an empathetic, consistent, and caring relationship to provide treatment

X Integrated care: Treatment combining mental health and medical care to improve overall functioning in the community; may also include access to dental care and pharmacy services

Z Colocation: Providing mental health and primary care services at a single site

X Supporting services to persons in housing: Effective in moving homeless persons with serious mental illness directly to independent housing with support and inten- sive attention

X Prevention: Beginning with discharge planning in inpatient settings, provide resourc- es for mental health care, housing, transitioning service, and follow-up

Migrant and Seasonal Farm Workers X Migrants: Persons who leave their permanent residences to take agricultural jobs in

different locations

X Seasonal: Workers who travel from their permanent residences seasonally for agri- cultural employment

X Men, women, and children of all cultures

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X It is estimated that more than 3 million migrant and seasonal farm workers work in the United States (National Center for Farmworker Health, 2009).

Z Hard to get an accurate census because families and workers move a great deal

X Working conditions, problems with the process of acculturation, isolation, discrimina- tion, and impaired access to health care play a role in a high prevalence of mental illness among migrant and seasonal farm workers.

X Very high incidence of depression, anxiety, and substance abuse

X Physical and emotional abuse of women is harder to address because of frequent changes of location.

X Meeting the mental health needs of this vulnerable population can pose a challenge because of the ways specific cultures perceive mental illness. Displaying an em- pathic, understanding, and culturally sensitive attitude is imperative when promoting care to this population.

Sexual Orientation Possessing a thorough understanding of sexuality is of great importance when communicating with clients of different sexual orientations. The practitioner must possess an open, supportive, sensitive, empathetic attitude toward the client. Understanding the client’s viewpoint and what he or she is seeking will help facilitate an effective psychiatric evaluation. In addition, an aware- ness of the factors the client may have faced because of his or her sexuality is crucial.

X Sexual identity: How people identify psychologically on a continuum between female and male and to whom they are sexually or affectionately attracted (Sadock, Sadock, & Ruiz, 2015)

X Gender identity: A person’s identity along a continuum between normative con- structs of masculinity and femininity

Z Influences of gender identity may consist of biological and social factors.

Z Biological factors may include pre- and postnatal hormone levels and gene expression.

Z Social factors may include gender messages from family, mass media, and cultural attitudes.

X Gender dysphoria: The formal diagnosis to describe a marked incongruence between one’s experienced and expressed gender and the gender assigned at birth (American Psychiatric Association [APA], 2013)

X Sexual orientation: The direction of sexual attraction; preferred over “sexual prefer- ence” or “lifestyle,” which imply choice, whereas “orientation” does not; some prefer “sexual identity” because it allows people to determine their own identities. Sexual orientation does not always relate to gender identity.

Z Asexual: Not attracted to either sex

Z Bisexual: Attracted to both sexes

Z Heterosexual: Attracted to the opposite sex

Z Homosexual: Attracted to the same sex

27Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

Z Transgender: Umbrella term describing persons whose gender identity does not conform to gender norms associated with the gender they were assigned at birth; does not imply a particular sexual orientation

Z Transsexual: Persons who identify as the opposite gender from the one they were assigned at birth; some change their bodies hormonally and surgically to conform to their gender identity

Z LGBTQ: Lesbian, gay, bisexual, transgender, and queer or questioning

Z Many clients seek treatment from a provider of the same orientation

X Sexual behavior: The manner in which humans experience and express their sexual- ity; includes attracting partners, sexual interactions, and social interactions (Sadock, Sadock, & Ruiz, 2015)

Forensics and Corrections In the 1970’s deinstitutionalization began, leaving many with a mental illness or intellectual dis- ability in need of housing in the community. One of the places persons with a mental illness are overrepresented is in the criminal justice system (Kennedy-Hendricks, Huskamp, Rutkow & Berry, 2016, pg. 1077). Persons in the prison system have higher rates of serious mental illness- es compared to those in the community (Prins, 2014). Prins found higher rates of post-traumatic stress disorder, major depression, generalized anxiety disorder, dysthymia, bipolar disorder, so- cial anxiety, panic, and schizophrenia in prison populations compared to community populations. A large number of US prisoners need mental health care. A case study of inmates in Texas found that approximately 15% to 24% of inmates reported symptoms of a psychotic disorder, 43% to 54% of inmates reported symptoms of mania, and 23% to 30% of inmates reported symptoms of major depression. Unfortunately, lack of synchronized care among criminal justice, mental, and public health systems results in repeat incarcerations (Baillargeon et al., 2010; Kushel, Hahn, Evans, Bangsberg, & Moss, 2005). It is essential to remain neutral, calm, and objective, and be skilled in self-reflective techniques as well as acknowledging one’s own emotional response and biases when providing care for imprisoned clients. Lyons (2009) recommends that the practitio- ner compartmentalize emotional responses and biases temporarily then debrief afterward.

X Forensic: The application of scientific knowledge to legal problems and legal pro- ceedings, for example, in forensic anthropology, forensic dentistry, forensic medicine (legal medicine), forensic pathology, and forensic science

X Forensic science: The application of a broad range of sciences to answer questions of interest to the legal system; a high-technology field using electron microscopes, lasers, ultraviolet and infrared light, advanced analytical techniques, and computer- ized databanks to analyze and research evidence

X Forensic nursing: The practice of nursing when health and legal systems intersect; the forensic nurse provides direct services to individual clients; consultation services to nursing, medical, and legal agencies; and expert court testimony in areas dealing with trauma or investigations of questioned deaths, adequacy of services delivery, and specialized diagnoses of specific conditions as related to nursing

Forensic Versus Correctional

X Forensic: Nurse–client relationship based on crime committed and investigational aspect of the interaction

28 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

X Correctional: Nurse–client relationship based on offender’s current mental health and medical conditions

X Locations: Emergency departments, prisons (high-, medium-, and low-security units), courts, and police stations (Lyons, 2009)

Forensic Knowledge Base

X Relies on evidence-based practice as well as past clinical experience

X Incorporates both criminal justice and mental health systems

X The forensic PMHNP should possess theoretical and practical knowledge of the criminal justice and mental health systems

Z Function of the court

Z Litigation procedures

Z Workings of the criminal justice system

Z Relevant case law and health litigation

Z Understanding of mental health, distorted thinking patterns, and impaired cognition

Z Competence: Safety, security, management, and assessment of risk; management of aggression and violence; therapeutic relationship; offending behavior knowledge; prison culture; documentation; medical knowledge; psychopharmacology; and crisis de-escalation (Lyons, 2009)

Forensic Risk Assessment vs . Risk Assessment

X Forensic risk assessment: Protect the public from persons with known mental disor- ders having dangerous, violent, and criminal histories

X Risk assessment: Psychiatric evaluation performed in emergency department after arrest and before person is confined to a correctional facility (Lyons, 2009)

29Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

CASE STUDY 1 Karen Harris is a newly graduated PMHNP. She worked as a psychiatric nurse for 5 years before going to graduate school. She is considering a job at the local community mental health center. The director of the center has told her that her role would consist of seeing mainly adult clients with serious, chronic, and persistent mental illness.

On occasions when the psychiatrist is “busy,” Ms. Harris is told she may be expected to see a few children in addition to adults. The director expects Ms. Harris to provide medication manage- ment to well-known clients and occasionally to assist in diagnostic evaluations of new clients or clients in crisis. He also expects that she will “from time to time” meet the emergent medical needs of clients who have limited access to primary care providers, including the routine, ongo- ing care of nonpsychiatric disorders such as diabetes, hypertension, and chronic pain. Ms. Harris has many issues to consider before deciding to take or not take the position.

1. Would Ms. Harris be legally authorized to treat both children and adults?

2. What regulation, rule, or standard should Ms. Harris consult to determine if she is legally allowed to treat both children and adults?

3. What regulation, rule, or standard should Ms. Harris consult to determine if she is legally allowed to treat both physical and psychiatric disorders?

4. What is the role of professional psychiatric nursing organizations in assisting Ms. Harris to determine the scope of practice that is appropriate for her as a new graduate?

Ms. Harris decides not to take that job and instead has been working for about a year as a PMHNP in a nurse-managed primary mental health clinic. One day she is asked to assess a client who is clearly psychotic, experiencing hallucinations and delusions, and expressing verbal threats against many persons at another clinical practice in town who had “malpracticed” them. The client is adamant that he does not wish any treatment and that he is not ill. To care for this client, Ms. Harris has many issues to consider.

5. Is Ms. Harris able to treat the client if he is not consenting to care?

6. What legal standards must be met if she is to treat this client without his consent?

About 5 weeks later the above-mentioned client returns to the clinic for follow-up care. He is clinically stable, on medication, and showing no active symptoms. He is interested in developing a relapse prevention plan and asks Ms. Harris to assist him in this process. Ms. Harris has many issues to consider.

7. Is the inclusion of a durable power of attorney an appropriate strategy in relapse planning for this client?

8. What quality indicators should be considered in planning the client’s care with him?

9. What risk management and liability issues should Ms. Harris consider?

CASE STUDY 2 A PMHNP working in a rural mental health clinic is asked by a women’s clinic to evaluate Ms. M., a 35-year-old female. Ms. M. insists she is not depressed, but that she has been feeling under- standably distressed because she was fired from her job for excessive absenteeism related to “head, neck, and back pain.” Ms. M. has difficulty falling and staying asleep, wakes up feel- ing tearful, and doesn’t want to get out of bed. She has become socially isolative and spends

30 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

hours sitting in front of the television. She has been taking 50 mg of amitriptyline for the past 6 months. The medication has been prescribed by a physician’s assistant at a women’s clinic. She was last seen at the women’s clinic 4 months ago. After evaluating Ms. M., the PMHNP de- cides that she meets criteria for major depression. He decides to continue the amitriptyline but increases the dose.

1. How should the PMHNP explain his rationale for increasing the dose of the amitrip- tyline to the client?

2. Since amitriptyline is a tricyclic antidepressant, is it reasonable for the PMHNP to continue and even adjust the dose of this medication—in other words, is this treat- ment within the scope of the PMHNP’s practice?

31Psychiatric–Mental health nurse Practitioner role, scoPe of Practice, and regulatory Process

ANSWERS TO CASE STUDY DISCUSSION QUESTIONS

Case Study 1 1. The key word here is “legally.” Professional standards and scope of practice docu-

ments suggest what is reasonable and prudent practice. Professional nursing organizations will provide information on what is seen as acceptable educational preparation for practice. However, the individual legislative regulations of each state determine what constitutes legal practice for each individual PMHNP.

2. The Nurse Practice Act and related legislation of the state in which she practices will delineate the legal boundaries of her practice.

3. Professional standards and scope-of-practice documents suggest what is reasonable and prudent practice. The individual legislative regulations of each state determine what constitutes legal practice for each individual PMHNP.

4. Professional nursing organizations provide information through a Scope and Standards document about what is seen as an acceptable practice role for PMHNPs, but the PMHNP’s practice is ultimately guided by the individual state’s Nurse Practice Act.

5. Any client, including a psychiatric client, has the right to refuse treatment. Ms. Harris is legally and ethically bound to honor the client’s rights.

6. Ms. Harris must meet the legal standard in the state where she practices to treat a client against his or her wishes. This usually entails performing the legal task of com- mitting a client and in most states, ensuring that the following criteria are met:

Z The person has a diagnosed psychiatric disorder

Z The person is unaware or unwilling to accept the nature and severity of disorder

Z As a result of a mental disorder, a person is harmful to self or others

Z As a result of a mental disorder, a person cannot take care of his or her basic needs of food, clothing, and shelter

7. A durable power of attorney allows a person in a state of health to choose another person to act on his or her behalf should he or she become unable to make his or her own healthcare decisions. Chronic mental illness has the potential to render a person unable to make healthcare decisions, and a durable power of attorney docu- ment should be part of relapse planning.

8. Standardized client assessment and rating scales, evidence-based standards of care, and measures of quality, including client and family satisfaction, should be considered.

9. Ms. Harris should adhere to standards and scope of practice and identify factors specific to this client that increase liability exposure.

Case Study 2 1. The PMHNP must discuss the treatment plan in the context of the client’s psychi-

atric symptoms. Without trying to convince the client that she has major depres- sion, the PMHNP can discuss how chronic pain may have led to the distress she is

32 Psychiatric-Mental health nurse Practitioner review and resource Manual, 4th edition

currently experiencing and that the medication may address many of her distressing symptoms. He will also need to address the potential side effects from this tricyclic antidepressant, and the usual course of treatment in terms of dosing and timeline.

2. Yes, if the PMHNP is using the medication to target the client’s depressive symp- toms and if he believes the benefit-to-risk ratio is reasonable in this instance, it is reasonable for the PMHNP to continue the medication and adjust the dose. The PMHNP must do all the relevant medical tests to prescribe this medication.

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