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Development of Psychiatric–Mental Health Nurse Practitioner Competencies: Opportunities for the 21st Century

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The purpose of this article is to discuss the development of the psychiatric–mental health nurse practitioner(PMHNP) competencies. The historical context and controversy regarding the role of advanced practice psychiatric mental health nursing as well as the consensus process of a national panel charged with the development of these competencies are described. Also, implications for education, practice, research, and policy are examined. The PMHNP competencies is a seminal document that will provide direction for the future of advanced practice psychiatric–mental health nursing.
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WheelerandHaberDevelopmentofPsychiatric–MentalHealthNursePractitionerCompetencies
Development of Psychiatric–Mental Health
Nurse Practitioner Competencies:
Opportunities for the 21st Century
Kathleen Wheeler and Judith Haber
The purpose of this article is to discuss the development of the psychiatric–mental health nurse practitioner (PMHNP) competen-
cies.The historical context and controversy regarding the role of advanced practice psychiatric mental health nursing as well as
the consensus process of a national panel charged with the development of these competencies are described. Also, implications
for education, practice, research, and policy are examined. The PMHNP competencies is a seminal document that will provide
direction for the future of advanced practice psychiatric–mental health nursing. J Am Psychiatr Nurses Assoc, 2004; 10(3),
129-138. DOI: 10.1177/1078390304266218
Keywords: psychiatric–mental health nursing; competencies; advanced practice nursing
The emerging role of the psychiatric–mental health
nurse practitioner (PMHNP) has gradually gained mo-
mentum over the last 10 years. This article describes
the historical context and controversy regarding scope
of practice, titling, competencies, and certification of
the PMHNP. The process undertaken to identify and
validate the competencies for this specialty is dis-
cussed, and future implications for advanced practice
psychiatric nursing are explored.
In August 2000, the Division of Nursing,Health Re-
sources and Services Administration (HRSA), U.S. De-
partment of Health and Human Services, funded the
National Organization of Nurse Practitioner Faculties
(NONPF) to develop entry-level nurse practitioner
(NP) competencies in five primary care specialty ar-
eas—adult, family, gerontological, pediatric, and
women’s health. The work was completed in partner-
ship with the American Association of Colleges of
Nursing (AACN) and released to the public in fall 2001
(NONPF, 2002). The intent was to establish specialty
competencies that articulated with NONPF’s already
existing NP core competencies to serve as guides for
developing, evaluating, and revising educational
programs and NP curricula.
National, consensus-based entry-level competen-
cies for PMHNP were not part of the initial project but,
when initiated in 2002, were modeled after the project
funded by HRSA. The PMHNP initiative was a collabo-
ration between the national psychiatric nursing spe-
cialty and related professional organizations (Table 1)
that were stakeholders in developing competencies for
this group. The project, facilitated and funded by
NONPF, began with a special interest group (SIG) for
advanced practice psychiatric–mental health nurses
convened at the NONPF annual national conference in
April 2002.
HISTORICAL CONTEXT
AND BACKGROUND
Since 1954 when the first clinical nurse specialist
(CNS) graduate program in psychiatric nursing was
started by Hildegard Peplau, advanced practice
psychiatric–mental health nurses have been educa-
tionally prepared in master’s programs. They have
been direct providers of expert patient care, as well
as consultants, educators, and researchers, and they
have served as a resource for nurses across a broad
spectrum of clinical inpatient as well as community
Copyright
©
2004 American Psychiatric Nurses Association 129
Kathleen Wheeler, APRN, BC, PhD, professor, School of Nursing,
Fairfield University, Fairfield, CT; kwheeler@fair1.fairfield.edu.
Judith Haber,APRN, BC, PhD, FAAN, professor, director of Grad-
uate Programs, School of Nursing, New York University, New
Yor k .
The authors acknowledge the work of the National Panel for
Psychiatric–Mental Health Nurse Practitioner Competencies
and discussion with Dr. Grayce Sills in preparing this article.
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settings (Lego, 1996). Over the years, the curriculum
in psychiatric–mental health CNS (PMHCNS) grad-
uate programs changed to reflect the neurobiological
knowledge explosion of the 1990s and the “Decade of
the Brain,” to meet emerging societal needs, and to
address the evolution of the advanced practice role.
As such, PMHCNS programs began to include health
assessment, pharmacology, pathophysiology, and/or
neurophysiology as well as an increase in the number
of required clinical hours (Delaney, Chisolm, Clem-
ent, & Merwin, 1999; Naegle & Krainovich-Miller,
2001).
In contrast to the genesis of PMHCNS education,
the first NP program was developed in 1965 by Loretta
Ford at the University of Colorado. The NP program
was based on a model for health promotion and disease
prevention for a pediatric population. The NP was de-
veloped in an effort to address the primary care physi-
cian shortage. The intent was that NPs, under the di-
rection of physicians, would provide services to a
specific population (Mezey & McGivern, 2004). NPs
were educated in certificate programs; neither a bache-
lor’s nor a master’s degree was required.Thus, the orig-
inal purpose and educational preparation for the NP
and CNS programs were significantly different.
In the 1970s, NP education began to be offered in
graduate programs. By 1979, The National League for
Nursing (NLN) published a position paper stating that
NPs needed a master’s degree in nursing to practice
competently (NLN, 1979). The American Nurses
Credentialing Center (ANCC), as of 1993, required a
graduate degree for NP certification. Since then, ad-
vanced practice nurses have been prepared as either
CNSs or NPs in master’s degree programs. Today, NP
education also takes place in post-master’s programs;
the original primary care NP specialties have evolved
to include other specialties,such as psychiatric–mental
health, acute care, palliative, oncology, and holistic
care.
SOCIETAL CHANGES AND PSYCHIATRIC
NURSING GRADUATE EDUCATION
The impetus for academic, certification, and regula-
tory reform in advanced practice psychiatric–mental
health nursing in the 1990s was a result of a number of
significant societal and health care system trends over
the past decade (Caverly, 1996; Cukr, Jones, Wilberger,
Smith, & Stopper, 1998; Flaskerud & Wuerker, 1999;
Krauss, 1993; Thomas, Brandt, & O’Connor, 1999;
White, 2000; Williams et al., 1998). The NP title was
recognized, and enrollment in PMHCNS educational
programs decreased as did the number of CNS posi-
tions in the hospital settings. Health care changes
included an emphasis on primary care; an increased
understanding of the importance of a healthy mind for
physical health; integration of systems of care; and
identification of a growing number of underserved vul-
nerable populations, such as the homeless, women,
children, and the unemployed, who did not have access
to mental health care. Other trends were the result of
research that supported the significant physical and
psychiatric comorbidities for those with mental illness.
Finally, there was enhanced awareness of the cost,
financially and socially, of psychiatric disorders.
In response to these trends, an array of psychiatric–
mental health nursing graduate programs developed.
Five types have been identified in the literature (Cukr
et al., 1998; Dyer, Hammill, Regan-Kubinski, Yurick, &
Kobert, 1997; Naegle & Krainovich-Miller, 2001;
Pasacreta, Minarik, Cataldo, Muller, & Scahill, 1999).
The earliest master’s programs prepared PMHCNSs.
Over time, other programs included components of the
CNS and NP roles in different arrangements: (a)
blended, one scope of practice that includes both the
CNS and NP roles with a set of core competencies un-
der one umbrella title—psychiatric–mental health ad-
vanced practice registered nurse; or (b) additive, pre-
pares as a PMHCNS and then continues for additional
education to become an NP.Finally,there are some edu-
cational programs that prepare primary care NPs but
with additional skills for the psychiatric population or
the “double NP,” a PMHNP plus an adult or family NP.
The diverse conceptualization of roles taught in these
advanced practice psychiatric–mental health nursing
programs concerned many within the specialty who
worried that the psychiatric–mental health advanced
practice nurse position was being eroded and in danger
of fragmentation and extinction because of so many di-
verse viewpoints. Indeed, a survey of 73 psychiatric
nursing graduate programs validated this concern and
found a diversity of programs with no consensus re-
garding what essential psychiatric–mental health con-
tent is (Delaney et al., 1999).
130 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3
Wheeler and Haber
TABLE 1. The National Panel for Psychiatric–Mental
Health Nurse Practitioners
Competencies Membership
American Nurses Credentialing Center (ANCC)
American Psychiatric Nurses Association (APNA)
International Nurses Society on Addictions (IntNSA)
International Society of Psychiatric Nurses (ISPN)
National Organization of Nurse Practitioner Faculties
Psychiatric–Mental Health Special Interest Group (NONPF SIG)
Note: There were a total of 13 members.
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There are advocates for all the different types of pro-
grams. Lego (1996) advocated for the PMHCNS role,
whereas others (Dyer et al., 1997; Puskar, 1996) sup-
ported the NP role for psychiatric–mental health ad-
vanced practice. There has been extensive support for
the dual roles, either the CNS and NP roles blended
into one program of study with a set of core competen-
cies (American Nurses Association, 2000; American
Psychiatric Nurses Association, 2003; Caverly, 1996;
Haber & Billings, 1995; Lynch, 1996; McCabe & Grover,
1999; Moller & Haber, 1996; Naegle & Krainovich-
Miller, 2001; Thomas et al., 1999; Williams et al., 1998)
or the additive approach, that is, PMHNP courses
added on after the CNS preparation (Cornwell &
Chiverton, 1997; Cukr et al., 1998). Finally, there have
been advocates for two distinct programs of study, one
for the CNS and one for the NP (Pasacreta et al.,1999).
The controversy regarding advanced practice
psychiatric–mental health nursing centers on the
scope of practice. Historically the advanced practice
psychiatric nurse has been identified with the CNS
roles of psychotherapist, educator, consultant, re-
searcher, and provider of treatment for acute and
chronic psychiatric disorders. There has been a more
recent shift to the primary care NP roles, which in-
cludes assessment; diagnosis; management of health
problems, including those psychiatric in nature; and
pharmacological treatment. In addition to role issues,
differences exist about the primary focus of care, men-
tal health problems, and psychiatric disorders or pri-
mary care problems. Is the PMHNP a medical primary
care provider with specialized education for meeting
mental health needs of the psychiatric patient or a psy-
chiatric care provider with specialized education for
meeting medical problems? The controversy about role
and focus of care is extremely important for the future
scope of practice, titling, education, and credentialing
for advanced practice psychiatric–mental health
nursing.
In addition to the above, there has been no agree-
ment about defining one set of core psychiatric–mental
health advanced practice registered nurse competen-
cies, which would include both psychosocial and
neurobiological content and drive development of an
advanced practice psychiatric–mental health core cur-
riculum. The need to clarify and specify an advanced
practice psychiatric–mental health model is of para-
mount importance to the specialty. The current spe-
cialty competencies provided an opportunity to take
the first step in that regard through development of
entry-level PMHNP competencies.
COMPETENCIES AND CERTIFICATION
Certification examinations reflecting competencies
for psychiatric advanced practice nurses were devel-
oped by the ANCC in the 1970s (Critchley, 1985). Until
1999, there were two certification exams for this spe-
cialty, the CNS in adult psychiatric nursing and the
clinical specialist in child/adolescent psychiatric nurs-
ing. In 1999, ANCC developed two additional certifica-
tions, the psychiatric adult NP and the psychiatric fam-
ily NP examinations. These were offered for the first
time in 2000.
The new exams were initiated as a result of several
converging events. Some psychiatric nursing leaders
advocated that a new national certification exam be de-
veloped that would better reflect the expanding knowl-
edge base and current realities of psychiatric advanced
practice (Johnson, 1998; McCabe & Grover, 1999;
Pasacreta et al., 1999). There was a proliferation of new
graduates from PMHNP programs that purported to
be markedly different from CNS programs. Most influ-
ential, some states would not permit PMHCNSs to pre-
scribe but did provide prescriptive privileges to NPs
(Hickey, 2000), and several states refused to grant
PMHNPs full scope of practice because there was no
national certification exam.
Although the ANCC believed that the psychiatric–
mental health credentialing examination was respon-
sive to the advanced practice nursing community, the
exam was developed without appropriate input and
representation from the major psychiatric nursing or-
ganizations. In addition, there was no grandfathering
Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3 131
Development of Psychiatric–Mental Health Nurse Practitioner
PMHNP
Graduate
Core
Curriculum
Certification
Exams
ANA
PMHAPRN
Scope and
Standards of
Practice
PMHNP
Core
Competencies
FIGURE 1. Scope of Practice Competency Curriculum
Credentialing Cycle
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mechanism for PMHCNSs who were already recog-
nized by their state as NPs or advanced practice regis-
tered nurses with prescriptive privileges.The NP exam
was viewed by many PMHCNSs as another hurdle to
overcome in order to practice as they already had prac-
ticed for many years. This also left educators who had
developed the PMHNP programs and those who
taught the courses in these programs in the unique po-
sition of being ineligible to take an exam for which they
were preparing their students (Rice, 2000). Educators
were left to ponder how to advise their graduates to
prepare for the examination, a PMHCNS review course
or an adult or family NP review course or perhaps both?
DEVELOPING THE PSYCHIATRIC–
MENTAL HEALTH NP COMPETENCIES
Historically, standards and competencies for the ad-
vanced practice registered nurse NP and CNS roles
have been developed by advanced practice nurses as
representatives of educational accreditation agencies
and professional nursing organizations. These have in-
cluded specialty organizations such as NONPF (2000,
2002), ANA (1994, 2000), APNA (2003), Society for Ed-
ucation and Research in Psychiatric–Mental Health
Nursing (SERPN, 1996), and AACN (1994, 1996).
The PMHNP competencies project was initiated
when the Psychiatric Mental Health Special Interest
Group (PMHSIG) officially formed at the NONPF con-
ference in April 2002. Shortly after this meeting, as an
extension of the Primary Care Specialty Competencies
Project funded by HRSA, NONPF decided to move for-
ward to identify competencies for the entry-level
PMHNP. The next month, five PMHSIG members, an
invited consultant, a graduate psychiatric NP student,
and a NONPF staff member met at Fairfield Univer-
sity in Fairfield, Connecticut, to launch the PMHNP
competencies. Two additional PMHSIG members par-
ticipated by conference call. The authors served as co-
chairs of the National Panel for the PMHNP Compe-
tencies project. During the initial meeting, a tentative
definition (Table 2) for the PMHNP was developed
based on the definition for the psychiatric–mental
health advanced practice registered nurse
(PMHAPRN) delineated in the ANA (2000) Scope and
Standards.
Given the turmoil and fragmentation that occurred
among PMHAPRNs over the last few years, a major ob-
jective of this initiative was to include a representative
group of stakeholders to achieve unity within the spe-
cialty. Thus, broad participation of clinicians, educa-
tors, and organizational executives was solicited to
compose the national panel. Representatives from or-
ganizations were invited to attend a meeting at New
York University. These individuals represented the
APNA, the International Society of Psychiatric Nurses
(ISPN), the International Nurses Society on Addictions
(IntNSA), AACN, ANCC, and NONPF (Table 1). A rep-
resentative from the National Association of Clinical
Nurse Specialists (NACNS) was invited as an observer.
A total of 13 representatives met over a 2-day period to
develop the PMHNP competencies.
All those participating recognized the historic signif-
icance of the meeting and the unique opportunity to
create a set of core competencies for PMHNP practice,
which would shape the nature and direction of curricu-
lum and program development, credentialing exams,
and of course, clinical practice. The intensity and qual-
ity of the completed work attested to the value placed
on the project.
Current literature and documents germane to the
task were identified and reviewed. Documents in-
cluded the ANA (2000) Scope and Standards of Psychi-
atric–Mental Health Nursing Practice, ANA’s (1996)
Scope and Standards of Advanced Practice Registered
Nursing, APNA’s (2003) position paper on titling and
credentialing, AACN’s (1996) Essentials of Master’s
Education,Educational Preparation for Psychiatric–
Mental Health Nursing (SERPN, 1996), Domains and
Core Competencies for Nurse Practitioner Practice
(NONPF, 2000), and Primary Care Specialty Compe-
tencies (NONPF, 2002).
Competencies were defined as “a combination of
skill, abilities, and knowledge needed to perform a
specific task” (U.S. Department of Education, 2002).
With this definition in mind, PMHNP competencies
were based on the ANA (2000) Scope and Standards
of Psychiatric–Mental Health Nursing Practice;they
expanded the NONPF core competencies using catego-
132 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3
Wheeler and Haber
TABLE 2. Definition of Psychiatric–Mental Health
Nurse Practitioner
“The psychiatric mental health nurse practitioner is an ad-
vanced practice registered nurse who focuses clinical prac-
tice on individuals, families, or populations across the life
span at risk for developing and/or having a diagnosis of psy-
chiatric disorders. The psychiatricmental health nur se practi-
tioner is a specialist who provides primary mental health
care to patients seeking mental health services in a wide
range of settings. Primary mental health care provided by the
psychiatric mental health nurse practitioner involves the con-
tinuous and comprehensive services necessary for the pro-
motion of optimal mental health, prevention and treatment
of mental illness, and health maintenance. This includes the
assessment, diagnosis, and management of mental health
problems and psychiatric disorders.
Note: From Haber and Billings (1995).
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ries that were consistent with those of the NONPF Do-
mains and Competencies for Nurse Practitioner Prac-
tice (2000) and the primary care specialty competencies
(2002). See Table 3 for the competency domains and
examples.
A working draft was completed by the end of the
New York meeting, reflecting a broad, inclusive scope of
practice for the PMHNP. Follow-up e-mail and confer-
ence calls assisted the national panel members in
reaching consensus on wording of competencies to fi-
nalize the document. Ten organizations were identified
and asked to invite representatives for the validation
process; they are listed in Table 4. Twenty-seven
validators were nominated by the organizations. They
were leaders from psychiatric nursing practice, educa-
tion, and accreditation organizations. A draft of the
PMHNP competencies was sent to members of the vali-
dation panel to assess the relevance, specificity, and
comprehensiveness of each competency. Twenty-one
validators responded, and 96% of the competencies
were deemed relevant. Approximately 50% of
competencies had suggestions for word changes with
respect to the specificity.
The draft, including validator suggestions, was
brought to the 2003 NONPF conference where inter-
ested parties, including those validators who were at-
tending the NONPF conference, met to discuss the
draft competencies, which included validator input.
Suggested changes in wording helped to clarify and
specify the meaning of numerous competencies. Sev-
eral additional competencies suggested by the
validators were added for the national panel’s consider-
ation and discussion. The national panel then held a
Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3 133
Development of Psychiatric–Mental Health Nurse Practitioner
TABLE 3. Domains and Competencies for
Psychiatric–Mental Health Nurse Practitioner
Related to Assessment, Diagnosis, and
Treatment (selected and abbreviated)
Health Promotion, Health Protection, and Treatment Assessment
1. Obtains and accurately documents a relevant health history,
with an emphasis on mental health history, for patient rele-
vant to specialty and age.
a. Performs a comprehensive physical and mental health
assessment.
b. Performs a comprehensive psychiatric evaluation that
includes evaluation of mental status, current and past
history of violence, suicidal or self-harm behavior,
substance use, level of functioning, health behaviors,
trauma, sexual behaviors, and social and developmental
history.
2. Analyzes the relationship between normal physiology and
specific system alterations associated with mental health
problems, psychiatric disorders, and treatment.
3. Collects data from multiple sources using assessment tech-
niques that are appropriate to the patient’s language, culture,
and developmental stage, including, but not limited to,
screening evaluations, psychiatric rating scales, genograms,
and other standardized instruments.
Diagnosis of Health Status
1. Orders and interprets findings of relevant diagnostic and lab-
oratory tests.
2. Identifies both typical and atypical presentations of psychiat-
ric disorders and related health problems.
3. Differentiates psychiatric presentations of medical conditions
from psychiatric disorders and arranges appropriate evalua-
tion and follow-up.
4. Develops a differential diagnosis derived from the collection
and synthesis of assessment data.
5. Diagnosis of psychiatric disorders.
Plan of Care and Implementation of Treatment
1. Develops a treatment plan for mental health problems and
psychiatric disorders based on biopsychosocial theories,
evidence-based standards of care, and practice guidelines.
2. Conducts individual, group, and/or family psychotherapy.
3. Treats acute and chronic psychiatric disorders and mental
health problems.
4. Plans care to minimize the development of complications
and promote function and quality of life using treatment mo-
dalities such as, but not limited to, psychotherapy and
psychopharmacology.
5. Prescribes psychotropic and related medications based on
clinical indicators of a patient’s status, including results of di-
agnostic and lab tests as appropriate, to treat symptoms of
psychiatric disorders and improve functional health status.
TABLE 4. Validators Panel
American Association of the College of Nurses (AACN)
American Association of Nurse Practitioners (AANP)
American Nurses Credentialing Center (ANCC)
American Nurses Association (ANA)
American Organization of Nurse Executives (AONE)
American Psychiatric Nurses Association (APNA)
Commission on Collegiate Nursing Education (CCNE)
International Nurses Society on Addictions (IntNSA)
International Society of Psychiatric Nurses (ISPN)
National Association of Clinical Nurse Specialists (NACNS)
National Organization of Nurse Practitioner Faculties
Psychiatric–Mental Health Special Interest Group (NONPF SIG)
TABLE 5. Endorsements
American Academy of Nurse Practitioners (AANP)
American Association of the College of Nurses (AACN)
American College of Nurse Practitioners (ACNP)
American Nurses Credentialing Center (ANCC)
American Nurses Association (ANA)
American Organization of Nurse Executives (AONE)
American Psychiatric Nurses Association (APNA)
Commission on Collegiate Nursing Education (CCNE)
International Nurses Society on Addictions (IntNSA)
International Society of Psychiatric Nurses (ISPN)
National League for Nursing Accrediting Commission (NLNAC)
National Organization of Nurse Practitioner Faculties
Psychiatric–Mental Health Special Interest Group (NONPF SIG)
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conference call to finalize the wording of competencies
and approved a final set of 68 competencies. The final
version was sent to major stakeholder nursing organi-
zations for endorsement (“philosophical agreement
with the intent and content of the competencies) in July
2003. Twelve endorsements were received by October
of 2003. Endorsing organizations are listed in Table 5.
IMPLICATIONS
Education
The PMHNP competencies (National Panel for
PMHNP Competencies, 2003) will contribute to shap-
ing graduate program curricula and will set the stan-
dard for advanced practice program development for
the next decade. They provide consensus regarding
what is essential PMHNP content for graduate pro-
grams and provide guidelines for development of a
broad-based curriculum that encompasses the full
scope of PMHNP practice that meets the specialty’s
standards and ensures academic accountability. Edu-
cational content needs to include all domains, biologi-
cal, social, and psychological, relevant to the PMHNP.
In turn, through competency-based education and
evaluation, specific behaviors of the PMHNP and
targeted patient outcomes can be more clearly
delineated.
Consistent with the APNA (2003) titling and
credentialing position paper and the AACN (1996) Es-
sentials of Master’s Education, required content in-
cludes the following:
Advanced Pathophysiology
Advanced Pharmacology
Advanced Health and Physical Assessment
Differential Diagnosis
Management and Evaluation of Mental Health Prob-
lems and Psychiatric Disorders
Individual, Group, and Family Therapy
Prescription of Psychopharmacological and Related
Medications
Leadership Development Related to Organization and
Management of Complex Delivery Systems
Clinical and Organizational Consultation
It is evident that psychotherapy and prescribing phar-
macologic agents are both integral with this PHMNP
role (ANA, 2000; APNA, 2003).
The competencies provide a template for educa-
tional programs to develop evaluation tools to measure
the outcomes of a competency-based curriculum. Eval-
uation studies can be designed using the competencies
in each domain to more fully measure the mastery of
PMHNP clinical competencies. The data derived from
such studies will provide the basis for developing strat-
egies for optimal teaching and learning. Models for ad-
vanced practice PMHNP education then can be vali-
dated using evidence-based decision making. It is
imperative that there are national standards and con-
sistency in graduate program curricula and that
credentialing bodies base their examinations on the
same practice-related competencies.
Post-master’s programs need to be developed to as-
sist those who need further knowledge and/or clinical
experience to acquire the core competencies embedded
in the PMHNP role. These programs should be flexibly
and creatively tailored to meet individual needs, and
the curriculum should not duplicate prior learning.
This may present a challenge to higher education in
nursing because creativity and flexibility are often
difficult in academe.
In addition to academic flexibility, confusion exists
regarding exactly what curricular content should be re-
quired. The Delaney et al. (1999) survey of graduate
faculty problems with the PMHNP certification exam
reported a great deal of confusion about the courses
needed for PMHCNSs who want to return to a post-
master’s program to sit for the exam (APNA, 2003). Be-
cause curricula for PMHCNSs vary widely, ANCC has
taken the position that it is the faculty who are in the
best position to decide on a case-by-case basis what
courses an individual student might need. ISPN and
APNA representatives are now working with ANCC in
developing criteria to help clarify the procedure for
determining readiness to take the NP exam.
Since the inception of the PMHNP, confusion has ex-
isted related to the similarities and distinctions in the
PMHCNS and PMHNP roles. Although developed spe-
cifically for NPs, the competencies are broad based and
may reflect the current nature of practice for both spe-
cialty roles, CNS and NP, consistent with the ANA
(2000) scope and standards of practice for the specialty
and APNA’s (2003) titling and credentialing position
paper. The PMHNP competencies will be reviewed by
the APNA Scope and Standards Task Force in relation
to the identified PMHCNS competencies to determine
the potential for a set of psychiatric advanced practice
registered nurse core competencies that transcend the
CNS and NP roles. This would be consistent with the
ANA (2000) Scope and Standards, the APNA (2003) ti-
tling and credentialing paper, and other specialty docu-
ments that support a single scope of practice, core com-
petencies, and core curriculum for advanced practice
psychiatric–mental health nurses. It is the major spe-
cialty documents, including the Scope and Standards,
position papers, and competencies, that define and in-
134 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3
Wheeler and Haber
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fluence curriculum development and credentialing. In
addition, such core competencies may also serve to in-
fluence nursing organizations worldwide in the design
and development of a model for international graduate
programs in psychiatric–mental health nursing.
As a result of the endorsement of the PMHNP com-
petencies, coupled with the recent Commission on Col-
legiate Nursing Education adoption of the Criteria for
Evaluation for Nurse Practitioner Programs (National
Task Force on Quality Nurse Practitioner Education,
2002) as a guideline for accreditation for NP programs,
it is incumbent upon PMHNP programs to ensure that
these evaluation criteria are followed. This may be
problematic for many NP programs. For example, the
criteria specify that the program must be directly coor-
dinated by an NP faculty member who is nationally
certified in the same specialty area and that NP faculty
in the specialty develop admission criteria and curric-
ula, evaluate the program, and determine progression
and graduation criteria. However, many of the PMHNP
programs were started and are taught by CNSs who do
not meet all of the ANCC PMHNP credentialing exam
eligibility criteria and were not offered a “grand-
mother” opportunity by ANCC even if they were titled
as NPs in their state. As such,there are few faculty who
are nationally certified PMHNPs and thus meet the
criteria. This remains a challenge for those involved
with graduate PMHNP education.
Practice
The PMHNP competencies describe entry-level ad-
vanced practice psychiatric nursing skills. The defini-
tion of the PMHNP (Table 2) as a specialist who pro-
vides primary mental health care in both inpatient and
outpatient settings provides an umbrella for many di-
verse roles; thus, practice may vary depending on set-
ting, patient population, and regional needs. PMHNPs
practice in traditional settings such as hospitals, pri-
vate practice, or community mental health outpatient
settings, or in more nontraditional settings such as
prisons, oncology, primary care offices, long-term care
facilities, and home health agencies. The definition al-
lows for innovative practice models, which are limited
only by the individual’s knowledge, skills, confidence,
and imagination.
In some settings, the PMHNP role may be seen as a
substitute for the psychiatrist, with the NP doing psy-
chiatric assessments and prescribing psychotropic
medications, whereas in other settings, more tradi-
tional roles such as consultation/liaison may be re-
quired. In all settings, however, the focus of care is the
same, providing comprehensive mental health and
psychiatric services necessary for the promotion of op-
timal mental health, prevention, and treatment of
psychiatric disorders.
Advanced practice psychiatric nurses can meet the
needs of a diverse complex system in a variety of posi-
tions. Practice subspecialties that are population based
or treatment based are likely to emerge with the
PMHNP competencies as foundational to that practice.
Subspecialties such as psychopharmacology, psycho-
therapy, mental health care of substance abuse pa-
tients, or geropsychiatry may eventually require certif-
ication specialty exams to be developed and
administered through psychiatric nursing certifying
organizations to ensure quality, safety, and consistency
of care.
The definition of the PMHNP addresses scope of
practice issues and provides a clear compass for the fu-
ture role of the PMHNP. The debate regarding whether
primary care or mental health care should be the focus
of care for PMHNPs is resolved. Primary mental health
care, not primary care, is essential to the role of the
PMHNP. The PMHNP assesses, diagnoses, and man-
ages acute and chronic mental health problems and
psychiatric disorders. Integral with this focus is knowl-
edge of medical disorders, which is important to de-
velop a differential diagnosis or evaluate comorbidities.
For example, diagnosing hypothyroidism versus de-
pression or evaluating adverse effects of
psychopharmacological treatment such as diabetes
insipidus, agranulocytosis, or tardive dyskinesia, or
monitoring laboratory tests needed for assessment and
evaluation of pharmacological agents, are all impor-
tant clinical skills for the PMHNP (Moller & Haber,
1996; Talley & Caverly, 1994; Wheeler & Haber, 2003).
In addition, because many psychiatric patients have
comorbidities such as schizophrenia and diabetes or
fibromyalgia and depression, it is crucial that the
PMHNP possess the skills to assess and diagnose
medical problems and/or refer appropriately to
primary care or specialty providers when needed.
Another salient issue related to primary mental
health care practice is that the PMHNP conducts indi-
vidual, group, and/or family psychotherapy. This is
noteworthy because many of the existing psychiatric
NP programs have no courses or practicum experiences
in psychotherapy. Integrating theory and teaching the
skills needed to provide psychotherapy services along
with neurobiological and psychopharmacological man-
agement is essential for entry-level PMHNP practice.
Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3 135
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This role clearly differentiates the specialty from other
advanced practice specialties such as adult or family
NPs.
The competencies guide students regarding the role
and expectations for entry-level PMHNP practice and
provide clarity about exciting practice opportunities for
the future. With this in mind, one can anticipate that
more students will be recruited into the specialty. New
PMHNP students can benefit from knowledge about
the competencies so that practice parameters are real-
istic while using them as benchmarks for excellence. In
addition, the competencies provide consumers, employ-
ers, and public or private sector third-party payers with
clarity regarding the scope of practice of PMHNPs.This
may also serve to inform the nursing profession and
other health care providers about the PMHNP scope of
practice. Consequently, there will be many practice op-
portunities in a wide variety of settings for those
prepared for multiple roles as a PMHNP.
Research and Policy
The PMHNP competencies will assist nursing orga-
nizations, educators, and the federal government to
identify mental health outcomes that improve client
care and safety. Measuring performance based on these
competencies can assist in the generation of
researchable clinical questions that contribute to un-
derstanding the interface of complex clinical variables
that are addressed through testing the efficacy of
PMHNP interventions and studying the outcomes.
Outcomes provide a benchmark of excellence for prac-
tice standards and demonstrate through evidence how
PMHNPs make a difference in patient outcomes.
Inclarifyingtheroleandscopeofpractice,PMHNP
outcome studies need to demonstrate the quality and
cost-effectiveness of these services. Research has al-
ready documented the efficacy of NP services for other
specialties (Brown & Grimes, 1995; Mundinger et al.,
2000). Outcome studies comparing the efficacy of dif-
ferent mental health professions are important and
can be accomplished using the competencies to define
the specialty. The data fromsuch studies can be used to
influence health policy and legislation at the local, re-
gional, and national levels related to enhancing access,
reimbursement, and program funding.
The next step in outcome development, according to
the president of NONPF, is further explication of the
competencies for each specialty (D. Viens, personal
communication, September 15, 2003). That is, delineat-
ing behaviors or indicators that those in the specialty
agree upon as necessary for meeting that competency.
Forexample,thePMHNPmustbeabletoperforma
comprehensive physical and mental health assessment
(Table 3).What are the measurement criteria for deter-
mining this proficiency in an entry-level provider? Are
a certain number of physical exams required to meet
the competency? How are competency-based outcomes
quantified? Viens believes the next developmental step
for the process is further specification of behaviors
necessary to meet each competency.
In addition to serving as a compass for outcome mea-
surement, the competencies reflect the consensus of
the specialty in defining the role of the PMHNP, which
informs the ANCC and other professional nursing
credentialing and accreditation organizations regard-
ing performance standards. Thus, state boards of nurs-
ing (SBONs), as well as the public, can be assured that
the criteria for standards of practice reflect account-
ability to the profession, the specialty, and society.
These standards then may serve as a legal document in
cases where there are questions whether standards
have been met.
Given the PMHNP competencies, several opportuni-
ties and challenges exist for the specialty. They include
developing a standardized PMHNP core curriculum
that reflects the competencies, and resolving whether
the PMHNP competencies developed in the current
project also define the core competencies for
PMHCNSs and, as such, reflect PMHAPRN core com-
petencies as delineated in the ANA (2000) Scope and
Standards, the APNA (2003) titling and credentialing
position paper, and the SERPN (1996) guidelines for
graduate education in psychiatric–mental health nurs-
ing practice. Specialty organizations need to influence
alignment of current and future PMHNP role delinea-
tion with credentialing exams to ensure that the
PMHNP competencies identified in the consensus spe-
cialty document are tested. Other challenges, such as
clarifying the content focus of the ANCC family psychi-
atric NP certification exam, supporting PMHNP certif-
ication “transition” mechanisms for PMHCNSs who
have state NP title recognition (or its equivalent) and
prescriptive authority, and exploring the potential for
an APNA self-certification program, demand the atten-
tion of psychiatric–mental health nursing leadership.
These opportunities and challenges are significant and
require the collaboration of psychiatric nursing spe-
cialty, education, and credentialing organizations
(Bjorklund, 2003; Caverly, 1996; Haber & Billings,
1995; Moller & Haber, 1996; Talley & Brooke, 1992).
CONCLUSIONS
Peplau (1965) proposed that social forces of techno-
logical advances precede areas of specialization in
136 Journal of the American Psychiatric Nurses Association, Vol. 10, No. 3
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nursing in response to public and societal needs and in-
creased specialty information. Given the tumultuous
nature of change in the last decade of the 20th century,
all of these forces have converged to propel advanced
practice psychiatric nursing forward into uncharted
territory that is now being defined through this historic
NONPF PMHNP competencies project. It is expected
that review and revision of these competencies will be
ongoing as new trends in health care emerge.
The PMHNP competencies have the potential to
unify advanced practice psychiatric nursing, prevent
fragmentation of the specialty, strengthen the ad-
vanced practice psychiatric nursing role, and provide a
model for other emerging advanced practice special-
ties. Unity among the advanced practice specialties is
strengthened when competencies parallel those of
other specialty advanced practice registered nurses.
Moreover, the prescient PMHNP competencies ad-
vance the practice of psychiatric nursing toward a sig-
nificant paradigm shift, a practice responsive to social
and health care needs that positions the specialty with
expanded opportunities and direction for the future
into the 21st century.
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As advanced practice psychiatric-mental health nursing has transitioned from earlier models of practice, elements of clinical specialist and psychiatric nurse practitioner roles are being blended to produce a new type of practitioner. The challenge of preserving mental health expertise while expanding advanced practice primary and primary mental health care competencies is addressed in several nursing education models. At New York University's Division of Nursing, faculty have designed a program around elements identified as essential to the autonomy demanded of the evolving role, knowledge, and skills basic to broad based health care and mental health care delivery with quality patient care outcomes and the competencies necessary for accountability as care providers in a changing health care delivery system. Essential elements, resources to identify them, and strategies to attain them are discussed. Approaches that promote student, clinician, and faculty development and maximize education affirm the spec...
As new models of health care delivery evolve, the work of advanced practice nurses is growing in importance. Graduate programs in nursing have traditionally prepared advanced practice nurses for separate roles as clinical nurse specialists or as nurse practitioners. However, there are increasing trends toward the blurring of boundaries between these two types of advanced practice roles. Hence, a future blended role is projected by many nurse educators. The merger of clinical nurse specialist and nurse practitioner roles, however, requires corresponding shifts in academic programs. The purposes of this article are to discuss the need for a blended clinical specialist-nurse practitioner role in mental health, to identify populations of clients who would be served by a blended role provider, to discuss the competencies associated with such a role, and to share an approach to the preparation of advanced practice mental health specialist/practitioners.
This article introduces and defines the concept of primary mental health care, a model for the delivery of community-based, comprehensive psychiatric-mental health nurs ing care. The primary mental health care model incorporates professional role re sponsibilities, role functions, and intervention activities for psychiatric-mental health nurses at the basic and advanced levels of practice. Use of this model will enable psychiatric nurses to articulate a nursing perspective about primary mental health care to colleagues, to policymakers, and to consumers. (J Am PSYCHIATR NURSES Assoc [1995]. 1, 154-163)