ANCC PMHNP CHAPTER 2 PSYCHIATRIC-MENTAL HEALTH NURSE PRACTITIONER ROLE, SCOPE OF PRACTICE, AND REGULATORY PROCESS questions and answers

All nurse practitioners upon graduation are expected to meet

NURSE PRACTITIONER ADVANCED PRACTICE CORE CONTENT

a set of core competencies

Specialty competencies, such as the Psychiatric-Mental Health Nurse Practitioner Competencies, are then built upon these core competencies (NONPF, 2013).

Nurse Practitioner Core Competencies are based on

"THE Q SLIPP"

*Technology and Information Literacy

*Health Delivery System

*Ethics

*Quality

* Scientific Foundations

*Leadership

*Practice Inquiry

*Independent Practice

*Policy

What are the 3) MHNP Leadership Competencies

Leadership Competencies

1)Participates in and evaluate community/population-focused programs that:

promote mental health

prevent or reduce risk of mental health problems

2)Advocates for complex client and family medicolegal rights and issues

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

Quality Competencies

Quality Competencies

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

Policy Competencies

Policy Competencies

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

Independent Practice Competencies

Develops age-appropriate treatment plans

Includes differential diagnosis

Assesses impact of acute and chronic medical problems on psychiatric treatment

Conducts individual and group psychotherapy

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

Applies recovery-oriented principles

Demonstrates best practices of family care approaches

Plans care to minimize the development of complications and promote function

Treats acute and chronic psychiatric disorders and problems

Safely prescribes pharmacologic agents

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

Explains the risks and benefits of treatment to client and family

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

Seeks consultation

Uses self-reflection to improve care

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

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

Uses individualized outcome measure to evaluate psychiatric care

Manages psychiatric emergencies

Refers clients appropriately

Facilitates the transition of clients across levels of care

Uses outcomes to evaluate care

Attends to the client-NP relationship as a vehicle for change

Maintains a therapeutic relationship over time with individuals and groups

Therapeutically concludes the client-NP relationship

Demonstrates ability to address sexual and physical abuse, substance abuse, sexuality, and spiritual conflicts

Applies therapeutic relationship strategies based on theory and research

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

Identifies and maintains professional boundaries

Teaches clients, families, and groups

Provides psychoeducation

Modifies the treatment approach based on client readiness

Considers motivation and readiness to improve self-care

Demonstrates knowledge of appropriate use of seclusion and restraint

Documents appropriate use of seclusion and restraint

The NP role was introduced in what year by whom?

discuss HX

HISTORY OF THE NP ROLE

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 performing 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 educational preparation for this new role.

As part of the LACE model, Psychiatric-Mental Health was identified as a population focus. 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 acceptance 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).

In ______ year the License, Accreditation, Certification, and Education (LACE) consensus model was finalized and adopted by many nursing organizations. The consensus model identified what four

Advanced Practice Registered Nurse roles?

2008

Certified Registered Nurse Anesthetist (CRNA), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), and Certified Nurse Practitioner

(CNP)

Growth of the NP Role

Growth of the NP Role

Facilitating factors for growth

*Consumer demand for services

*Acceptance of the advanced practice nursing role

*Emergence of the PMHNP role

*Decreasing stigmatization

*Emphasis on integrated healthcare services

Constraining factors for growth

*Growing competition in job market in general for NPs

*Reimbursement struggles with Medicare and private insurance companies

*Overlapping scope of practice with other NPs

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

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

Regulatory and Statutory Dimensions of the NP Role

State legislative statutes & The Nurse Practice Act

Regulatory and Statutory Dimensions of the NP Role

State legislative statutes

* Grant legal authority for NP practice

The Nurse Practice Act of every state

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

* Defines advanced practice

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

* Places restrictions on practice

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

* States grounds for disciplinary action:

** Practicing without valid license

** Falsification of records

** Medicare fraud

** Failure to use appropriate nursing judgment

** Failure to follow accepted nursing standards

** Failure to complete accurate nursing documentation

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

** 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

Regulatory and Statutory Dimensions of the NP Role

Statutory law, Licensure, Credentialing, Certification

Regulatory and Statutory Dimensions of the NP Role

Statutory law

* Rules and regulations differ for each state

* May further define scope of practice and practice requirements

* May provide restrictions in practice unique to specific state

Licensure

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

* Also prohibits all others from legally doing protected practice

Credentialing

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

Certification

* A credential that provides title protection

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

* 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

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

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

* 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.

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

Regulatory and Statutory Dimensions of the NP Role

Scope of Practice & Standards of Practice

Regulatory and Statutory Dimensions of the NP Role

Scope of practice

* Defines NP roles and actions

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

* Varies broadly from state to state

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

Standards of practice

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

* Provide a way to judge the nature of care provided

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

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

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

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

PROFESSIONAL ROLE RESPONSIBILITIES

Confidentiality

PROFESSIONAL ROLE RESPONSIBILITIES

Confidentiality

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

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

* Pertains to verbal and written client information

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

* 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

PROFESSIONAL ROLE RESPONSIBILITIES

HIPAA

PROFESSIONAL ROLE RESPONSIBILITIES

HIPAA

* The first national comprehensive privacy protection act

* Guarantees clients four fundamental rights:

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.

PROFESSIONAL ROLE RESPONSIBILITIES

The Health Information Technology for Economic and Clinical Health Act (HITECH)

PROFESSIONAL ROLE RESPONSIBILITIES

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

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

* Meaningful use incentives

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

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

* E-prescribing

* Computerized physician order sets

* Tracking care and avoiding duplication of services

PROFESSIONAL ROLE RESPONSIBILITIES

Telehealth

PROFESSIONAL ROLE RESPONSIBILITIES

Telehealth

* 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

* Must follow the same standards as care delivered in person

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

* Must include provisions for emergency care of the client

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

PROFESSIONAL ROLE RESPONSIBILITIES

Exceptions to guaranteed confidentiality

PROFESSIONAL ROLE RESPONSIBILITIES

Exceptions to guaranteed confidentiality

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

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

* Information given to attorneys involved in litigation

* Releasing records to insurance companies

* Answering court orders, subpoenas, or summonses

* Meeting state requirements for mandatory reporting of diseases or conditions

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

* In cases of child or elder abuse

PROFESSIONAL ROLE RESPONSIBILITIES

Informed consent

PROFESSIONAL ROLE RESPONSIBILITIES

Informed consent

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

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

* The right of all competent adults or emancipated minors

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

* Elements of informed consent

** Nature and purpose of proposed treatment or procedure

** Risks or discomforts and benefits of treatment

** Risks and benefits of not undergoing treatment

** Alternative procedures or treatments

** Diagnosis and prognosis

* Provider must document in the medical record that informed consent has been

obtained from the client.

* PMHNP is responsible for ensuring that the client is cognitively capable of giving

informed consent.

PROFESSIONAL ROLE RESPONSIBILITIES

Ethics

PROFESSIONAL ROLE RESPONSIBILITIES

Ethics

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

* What is right versus what is wrong

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

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

** Beneficence: Promoting well-being and doing good

** Nonmaleficence: Doing no harm

** Fidelity: Being true and loyal

** Autonomy: Doing for self

** Veracity: Telling the truth

** Respect: Treating everyone with equal respect

* 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.

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.

PROFESSIONAL ROLE RESPONSIBILITIES

Ethics 2

PROFESSIONAL ROLE RESPONSIBILITIES

Ethics 2

Important ethical principles in psychiatry

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

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

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

Ethical dilemma

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

* Occurs when the choice is made to promote good

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

Theoretical approaches to ethical decision-making

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

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

* 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

Ethics of Disclosure by Providers

* Clients have a right to know what is happening during the course of their treatment.

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

* 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).

Risk vs. Benefits of Disclosure of Disability Regarding Employment

Risk vs. Benefits of Disclosure of Disability Regarding Employment

* 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).

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

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

Risk of Disclosure

Risk of Disclosure

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

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

* Assumption that persons with psychiatric illnesses may be less productive

* May limit an employee's chance for advancement in career

* Feedback for improvement may not be given to employee because others may attribute the employee's behavior to the psychiatric illness.

* Labeling oneself as "disabled" may affect one's beliefs or self-image.

Benefits of Disclosure

Benefits of Disclosure

* Able to request reasonable accommodations

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

* Employee can involve an employment service provider, employee assistance program, or other third party in the development of accommodations.

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

* May help with the recovery process

* Allows coworkers to offer personal support

* May empower another employee to disclose

Legal Considerations

Legal Considerations

Malpractice insurance

* Provides financial protection against claims of malpractice

** Coverage for negligent professional acts

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

* Recommended universally for all NPs

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

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

* 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

Competency

*A legal, not a medical concept

*A determination that a client can make reasonable judgments and decisions regarding treatment and other health concerns

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

*If a person is deemed incompetent, a court-appointed guardian will make healthrelated decisions for that person.

Commitment

Commitment

* Process of forcing a person to receive involuntarily evaluation or treatment

* Process may differ from state to state

* Basic criteria include

** Person has a diagnosed psychiatric disorder,

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

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

** Treatment is likely to improve functioning.

* Involuntary admission

** Admission to a hospital or other treatment facility against the person's will

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

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

* Voluntary admission

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

** Client maintains all civil liberties

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

ROLES OF THE PMHNP

Scholarly Activities

ROLES OF THE PMHNP

Scholarly Activities

* It is important for NPs to engage in the following scholarly activities:

** Publishing

** Lecturing or presenting

** Preceptorship

** Continuing education

ROLES OF THE PMHNP

Mentoring

ROLES OF THE PMHNP

Mentoring

* A process in which a more experienced NP agrees to guide and support a junior colleague

in the role, competencies, and skills

* Requires mutual respect and an interactive process of learning

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

ROLES OF THE PMHNP

Client Advocacy

ROLES OF THE PMHNP

Client Advocacy

* Stand up for clients' rights and empower them to become their own advocates

* Reduce the stigma of mental illness

* Help clients receive available services

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

** American Nurses Association (ANA)

** American Psychiatric Nurses Association (APNA)

** International Society of Psychiatric Nurses (ISPN)

ROLES OF THE PMHNP

Health Policy

ROLES OF THE PMHNP

Health Policy

* Advanced practice nurses have a legal and ethical responsibility to be a client

advocate.

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

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

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

ROLES OF THE PMHNP

Case Management

ROLES OF THE PMHNP

Case Management

* A system of controlled oversight and authorization of services and benefits provided to clients

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

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

ROLES OF THE PMHNP

Risk Assessment

ROLES OF THE PMHNP

Risk Assessment

* Continuous monitoring for high-risk situations

* Assessing persons for nonhealthy behaviors

ROLES OF THE PMHNP

Risk Management

ROLES OF THE PMHNP

Risk Management

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

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

* Recognition and intervention to reduce subsequent claims against healthcare providers

Advance Directives

Advance Directives

*Durable power of attorney for health care. Also known as healthcare proxy

** Legally binding in all 50 states

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

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

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

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

** Not legally binding in all states

CULTURALLY COMPETENT CARE AND SPECIAL POPULATIONS

CULTURALLY COMPETENT CARE AND SPECIAL POPULATIONS

* Treating clients from diverse cultures, viewing each client as a unique person, and noting a potential relationship between clients' cultural experiences and their symptom presentation and perceptions

* 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

* 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

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

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

Cultural Influences and Determinants of Health

Cultural Influences and Determinants of Health

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

ZZ Concept broadened beyond the traditional husband-wife-children pattern

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

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

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

XX Environment: Includes both physical and psychosocial factors; the general circumstances

of a person's life:

ZZ Social contacts

ZZ Housing surroundings

ZZ Climate

ZZ Altitude

ZZ Temperature

ZZ Air pollution

ZZ Fluoride in water

ZZ Water contamination

ZZ Crime

ZZ Poverty

ZZ Transportation

Homelessness

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, alcohol, 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 population. Possessing appropriate communication skills and knowledge of available resources are invaluable.

Homeless person

ZZ 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

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

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

* 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.

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

Reasons for homelessness:

XX Mental illness

XX Addictive disorders

XX Poverty

XX Unemployment

XX Inadequate public assistance

XX Domestic violence

XX Lifestyle choice

Mental illness and addictive disorders in the homeless population:

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

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

ZZ Symptoms are often active and untreated.

ZZ 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.

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

Strategies for Reducing Homelessness

Strategies for Reducing Homelessness

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

XX 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

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

XX Supporting services to persons in housing: Effective in moving homeless persons with serious mental illness directly to independent housing with support and intensive attention

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

Migrant and Seasonal Farm Workers

Migrant and Seasonal Farm Workers

XX Migrants: Persons who leave their permanent residences to take agricultural jobs in different locations

XX Seasonal: Workers who travel from their permanent residences seasonally for agricultural employment

XX Men, women, and children of all cultures

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

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

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

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

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

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

Sexual Orientation

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 awareness

of the factors the client may have faced because of his or her sexuality is crucial.

XX 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)

XX Gender identity: A person's identity along a continuum between normative constructs of masculinity and femininity

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

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

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

XX 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)

XX Sexual orientation: The direction of sexual attraction; preferred over "sexual preference" 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.

ZZ Asexual: Not attracted to either sex

ZZ Bisexual: Attracted to both sexes

ZZ Heterosexual: Attracted to the opposite sex

ZZ Homosexual: Attracted to the same sex

ZZ 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

ZZ 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

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

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

XX Sexual behavior: The manner in which humans experience and express their sexuality; includes attracting partners, sexual interactions, and social interactions (Sadock,

Sadock, & Ruiz, 2015)

Forensics and Corrections

Forensics and Corrections

In the 1970's deinstitutionalization began, leaving many with a mental illness or intellectual disability 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 illnesses

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, social

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 practitioner compartmentalize emotional responses and biases temporarily then debrief afterward.

XX Forensic: The application of scientific knowledge to legal problems and legal proceedings, for example, in forensic anthropology, forensic dentistry, forensic medicine

(legal medicine), forensic pathology, and forensic science

XX 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 computerized

databanks to analyze and research evidence

XX 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

Forensic Versus Correctional

XX Forensic: Nurse-client relationship based on crime committed and investigational aspect of the interaction

XX Correctional: Nurse-client relationship based on offender's current mental health and medical conditions

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

Forensic Knowledge Base

Forensic Knowledge Base

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

XX Incorporates both criminal justice and mental health systems

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

ZZ Function of the court

ZZ Litigation procedures

ZZ Workings of the criminal justice system

ZZ Relevant case law and health litigation

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

ZZ 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

Forensic Risk Assessment vs. Risk Assessment

XX Forensic risk assessment: Protect the public from persons with known mental disorders having dangerous, violent, and criminal histories

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

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 management 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, ongoing 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?

ANSWERS TO CASE STUDY DISCUSSION QUESTIONS

Case Study 1

1. The key word here is "legally." Professional standards and scope of practice documents 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 committing a client and in most states, ensuring that the following criteria are met:

ZZ The person has a diagnosed psychiatric disorder

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

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

ZZ 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 document 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

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 understandably

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 feeling tearful, and doesn't want to get out of bed. She has become socially isolative and spends 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 decides 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 amitriptyline 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 treatment within the scope of the PMHNP's practice?

ANSWERS TO CASE STUDY DISCUSSION QUESTIONS

Case Study 2

1. The PMHNP must discuss the treatment plan in the context of the client's psychiatric symptoms. Without trying to convince the client that she has major depression, the PMHNP can discuss how chronic pain may have led to the distress she is 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 symptoms 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.