Psychiatric-Mental Health Nurse Practitioner Review & Resource Manual PDF

4TH EDITION Review and Resource Manual PSYCHIATRIC-MENTAL HEALTH Review and Resource Manual Nurse Practitioner Psychiatric-Mental Health NURSE PRACTITIONER PSYCHIATRIC- MENTAL HEALTH Review and Resource Manual, 4th Edition Are you looking into how to advance your professional development through NURSE 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 PRACTITIONER Nurse Practitioner certification exam. 4th Edition Based on the official ANCC certification exam test content outline, this review and resource manual will help you: n S tudy and analyze comprehensive material and concepts written by nursing experts. n D evelop a recommended seven-step plan to equip you for the exam and map out what to do on the day of the exam. n P repare for and familiarize yourself with psychological-mental health practitioner standards of practice. n A nd much more... Nursing Certification Review Manual Make the Psychiatric-Mental Health Nurse Practitioner Review Continuing Education Resource and Resource Manual a key resource in your certification preparation. Clinical Practice Resource Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC Dawn Vanderhoef, PhD, DNP, PMHNP-BC, PMHCNS-BC www.nursingknowledgecenter.org 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. 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. Review and Resource Manual Psychiatric– Mental Health Nurse Practitioner 4th Edition CONTINUING EDUCATION SOURCE NURSING CERTIFICATION REVIEW MANUAL CLINICAL PRACTICE RESOURCE Published by American Nurses Credentialing Center Kathryn Johnson, MSN, PMHNP-BC, PMHCNS-BC Dawn Vanderhoef, PhD, DNP, PMHNP-BC, PMHCNS-BC NURSING KNOWLEDGE CENTER 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 iii 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 CONTENTS v 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 CONTENTS vii 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 CONTENTS ix 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 [email protected]. 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. XX Remember, your program was designed to prepare you to take this exam. XX 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. XX 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. XX Remember that gossip about the exam that you hear from others is not verifiable. XX Because this gossip is based on the imperfect memory of people in a stressful situa- tion, it may not be very accurate. XX 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. 2 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition Step Three: Set Reasonable Expectations for Yourself XX Do not expect to know everything. XX Do not try to know everything in great detail. XX You do not need a perfect score to pass the exam. XX The exam is designed for a beginner level—it is testing readiness for entry-level practice. XX Learn the general rules, not the exceptions. XX The most likely diagnoses will be on the exam, not questions on rare diseases or atypical cases. XX Think about the most likely presentation and most common therapy. Step Four: Prepare Mentally and Physically XX While you are getting ready to take the exam, take good physical care of yourself. XX Get plenty of sleep and exercise, and eat well while preparing for the exam. XX 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. XX What content do you need to know? XX How well do you know these subjects? Take a Review Course XX Taking a review course is an excellent way to assess your knowledge of the content that will be included in the exam. XX 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. XX 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. XX If some topics in the review course are new to you, concentrate on these in your studies. XX 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. Taking The Certification Examination 3 Depth of Knowledge How much do you need to know about a subject? XX You cannot know everything about a topic. XX Remember that the depth of knowledge required to pass the exam is for entry-level performance. XX 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. XX Look at practice tests designed for the exam. Practice tests for other exams will not be helpful. XX 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. XX 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 XX Write up a formal plan of study. ZZ Include topics for study, timetable, resources, and methods of study that work for you. ZZ Decide whether you want to organize a study group or work alone. ZZ Schedule regular times to study. ZZ Avoid cramming; it is counterproductive. Try to schedule your study periods in 1-hour increments. XX Identify resources to use for studying. To prepare for the examination, you should have the following materials on your shelf: ZZ A good pathophysiology text. ZZ This review book. ZZ A physical assessment text. ZZ Your class notes. ZZ Other important sources, including: information from the testing facility, a clinical diagnosis textbook, favorite journal articles, notes from a review course, and practice tests. ZZ Know the important national standards of care for major illnesses. ZZ 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. XX Study the body systems from head to toe. 4 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition XX The exams emphasize health promotion, assessment, differential diagnosis, and plan of care for common problems. XX You will need to know facts and be able to interpret and analyze this information utilizing critical thinking. Personalize Your Study Plan XX How do you learn best? ZZ If you learn best by listening or talking, attend a review course or discuss topics with a colleague. XX 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. XX 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. XX Refer to your study plan regularly. XX Stick to your schedule. XX Take breaks when you get tired. XX If you start procrastinating, get help from a friend or reorganize your study plan. XX It is not necessary to follow your plan rigidly. Adjust as you learn where you need to spend more time. XX Memorize the basics of the content areas you will be required to know. Focus on General Material XX Most of what you need to know is basic material that does not require constant updating. XX 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 XX Stop studying for the examination when you are starting to feel overwhelmed and look at what is bothering you. Then make changes. XX Break overwhelming tasks into smaller tasks that you know you can do. XX Stop and take breaks while studying. Work With Others XX Talk with classmates about your preparation for the exam. XX Keep in touch with classmates, and help each other stick to your study plans. Taking The Certification Examination 5 XX If your classmates become anxious, do not let their anxiety affect you. Walk away if you need to. XX Do not believe bad stories you hear about other people’s experiences with previous exams. XX Remember, you know as much as anyone about what will be on the next exam! Consider a Study Group XX Study groups can provide practice in analyzing cases, interpreting questions, and critical thinking. XX You can discuss a topic and take turns presenting cases for the group to analyze. XX Study groups can also provide moral support and help you continue studying. Step Seven: Strategies Immediately Before the Exam Final Preparation Suggestions XX Use practice exams when studying to get accustomed to the exam format and time restrictions. ZZ Many books that are labeled as review books are simply a collection of examination questions. ZZ If you have test anxiety, such practice tests may help alleviate the anxiety. ZZ Practice tests can help you learn to judge the time it should take you to complete the exam. ZZ Practice tests are useful for gaining experience in analyzing questions. ZZ Books of questions may not uncover the gaps in your knowledge that a more systematic content review text will reveal. ZZ 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. XX Know your test-taking style. ZZ Do you rush through the exam without reading the questions thoroughly? ZZ Do you get stuck and dwell on a question for a long time? ZZ You should spend about 45 to 60 seconds per question and finish with time to review the questions you were not sure about. ZZ 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 XX Be prepared to get to the exam on time. ZZ Know the test site location and how long it takes to get there. ZZ 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 ZZ Get a good night’s sleep. ZZ Eat sensibly. ZZ Avoid alcohol the night before. ZZ 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. ZZ Know the exam room rules. XX You will be given scratch paper, which will be collected at the end of the exam. XX Nothing else is allowed in the exam room. XX You will be required to put papers, backpacks, etc., in a corner of the room or in a locker. XX No water or food will be allowed. XX You will be allowed to walk to a water fountain and go to the bathroom one at a time. The Day of the Exam XX 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. XX Think positively. You have studied hard and are well-prepared. XX 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. XX There is no substitute for being well-prepared. XX Practice relaxation techniques. XX Avoid alcohol, excess coffee, caffeine, and any new medications that might sedate you, dull your senses, or make you feel agitated. XX 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 XX Multiple-choice tests have specific rules for test construction. XX A multiple-choice question consists of three parts: the information (or stem), the question, and the four possible answers (one correct and three distracters). Taking The Certification Examination 7 XX Careful analysis of each part is necessary. Read the entire question before answering. XX Practice your test-taking skills by analyzing the practice questions in this book and on the ANCC website. Analyze the Information Given XX Do not assume you have more information than is given. XX Do not overanalyze. XX Remember, the writer of the question assumes this is all of the information needed to answer the question. XX If information is not given, it is not relevant and will not affect the answer. XX Do not make the question more complicated than it is. What Kind of Question Is Asked? XX Are you supposed to recall a fact, apply facts to a situation, or understand and dif- ferentiate between options? ZZ Read the question thinking about what the writer is asking. ZZ 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 XX 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. XX 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. XX After reading the entire question, go back, analyze the question, and select the best answer. XX Do not jump ahead. XX 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. XX If the question asks you for an intervention, do not answer with an assessment. avoid initial most best first significant except contributing to likely not appropriate 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 XX 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. XX If the answers include two options that are the opposite of each other, one of the two is probably the correct answer. XX When numeric answers cover a wide range, a number in the middle is more likely to be correct. XX 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. XX Err on the side of caution. Only One Answer Can Be Correct XX When more than one suggested answer is correct, you must identify the one that best answers the question asked. XX If you cannot choose between two answers, you have a 50% chance of getting it right if you guess. Avoid Changing Answers XX 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. XX People change to a wrong answer more often than to a right answer. Time Yourself to Complete the Whole Exam XX Do not spend a large amount of time on one question. XX If you cannot answer a question quickly, mark it and continue the exam. XX If time is left at the end, return to the difficult questions. XX Make educated guesses by eliminating the obviously wrong answers and choosing a likely answer even if you are not certain. XX Trust your instinct. XX Answer every question. There is no penalty for a wrong answer. XX 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. Taking The Certification Examination 9 XX 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. XX 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. XX The exam does not require computer expertise. XX 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. XX Each ANCC test question is independent of the other questions. ZZ 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. ZZ Each question has four possible answers. There are no questions asking for combinations of correct answers (such as “a and c”) or multiple-multiples. XX You can skip a question and go back to it at the end of the exam. XX You cannot mark key words in the question or right or wrong answers. If you want to do this, use the scratch paper. XX You will get your results immediately, and a grade report will be provided upon leav- ing the testing site. INTERNET RESOURCES XX ANCC website: www.nursecredentialing.org XX 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 XX National Guideline Clearinghouse: 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 XX Scientific Foundations XX Leadership XX Quality 12 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition XX Practice Inquiry XX Technology and Information Literacy XX Policy XX Health Delivery System XX Ethics XX 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 XX Participates in community and population-focused programs that evaluate programs and promote mental health and prevent or reduce risk of mental health problems XX Advocates for complex client and family medicolegal rights and issues XX Collaborates with interprofessional colleagues about advocacy, policy to reduce health disparities and improve outcomes for populations Quality Competencies XX Evaluates the appropriate uses of seclusion and restraints in the care process Policy Competencies XX 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 XX Develops age-appropriate treatment plans XX Includes differential diagnosis XX Assesses impact of acute and chronic medical problems on psychiatric treatment XX Conducts individual and group psychotherapy XX Applies supportive psychodynamic, cognitive, behavioral, and other evidence-based psychotherapies to brief and long-term practice XX Applies recovery-oriented principles XX Demonstrates best practices of family care approaches XX Plans care to minimize the development of complications and promote function XX Treats acute and chronic psychiatric disorders and problems Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 13 XX Safely prescribes pharmacologic agents XX Ensures client safety through the appropriate prescription of pharmacologic and nonpharmacologic interventions XX Explains the risks and benefits of treatment to client and family XX Identifies the role of PMHNP in risk mitigation strategies in areas of opiate use and substance abuse XX Seeks consultation XX Uses self-reflection to improve care XX Provides consultation to healthcare providers and others to enhance quality and cost XX Guides the client in evaluating the appropriate use of complementary and alternative treatment XX Uses individualized outcome measure to evaluate psychiatric care XX Manages psychiatric emergencies XX Refers clients appropriately XX Facilitates the transition of clients across levels of care XX Uses outcomes to evaluate care XX Attends to the client–NP relationship as a vehicle for change XX Maintains a therapeutic relationship over time with individuals and groups XX Therapeutically concludes the client–NP relationship XX Demonstrates ability to address sexual and physical abuse, substance abuse, sexual- ity, and spiritual conflicts XX Applies therapeutic relationship strategies based on theory and research XX Applies principles of self-efficacy, empowerment, and others to effect change XX Identifies and maintains professional boundaries XX Teaches clients, families, and groups XX Provides psychoeducation XX Modifies the treatment approach based on client readiness XX Considers motivation and readiness to improve self-care XX Demonstrates knowledge of appropriate use of seclusion and restraint XX 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. 14 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition 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 XX Facilitating factors for growth ZZ Consumer demand for services ZZ Acceptance of the advanced practice nursing role ZZ Emergence of the PMHNP role ZZ Decreasing stigmatization ZZ Emphasis on integrated healthcare services XX Constraining factors for growth ZZ Growing competition in job market in general for NPs ZZ Reimbursement struggles with Medicare and private insurance companies ZZ Overlapping scope of practice with other NPs ZZ Increased concerns over reimbursement fraud and abuse (e.g., issues of coding and billing for services) ZZ Scope of practice and need for formal supervisory or collaborative relationships with physicians Regulatory and Statutory Dimensions of the NP Role XX State legislative statutes ZZ Grant legal authority for NP practice ZZ The Nurse Practice Act of every state XX Provides title protection (who may be called a nurse practitioner) XX Defines advanced practice Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 15 XX Prevailing state laws that define scope of practice (what NPs may do) XX Places restrictions on practice XX Sets NP credentialing requirements (e.g., educational requirements, certification) XX States grounds for disciplinary action: ZZ Practicing without valid license ZZ Falsification of records ZZ Medicare fraud ZZ Failure to use appropriate nursing judgment ZZ Failure to follow accepted nursing standards ZZ Failure to complete accurate nursing documentation XX May specifically require that an NP develop a collaborative agreement with a physician ZZ 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 XX Statutory law ZZ Rules and regulations differ for each state ZZ May further define scope of practice and practice requirements ZZ May provide restrictions in practice unique to specific state XX Licensure ZZ A process by which an agency of state government grants permission to persons to engage in the practice of that profession ZZ Also prohibits all others from legally doing protected practice XX Credentialing ZZ Process used to protect the public by ensuring a minimum level of professional competence XX Certification ZZ A credential that provides title protection ZZ Determines scope of practice (i.e., whom NPs can see and what NPs can treat) ZZ 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 ZZ Assures the public that a person has mastery of a specified body of knowledge ZZ Assures that the person has acquired the skills necessary to function in a particular specialty 16 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition ZZ 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. XX Certification offered as a Psychiatric–Mental Health Nurse Practitioner–Life Span (ANCC, 2015) XX Scope of practice ZZ Defines NP roles and actions ZZ Identifies competencies assumed to be held by all NPs who function in a particular role ZZ Varies broadly from state to state ZZ Advanced practice PMHNP standards are identified in Psychiatric-Mental Health Nursing: Scope and Standards of Practice (ANA, 2014). XX Standards of practice ZZ Authoritative statements regarding the quality and type of practice that should be provided ZZ Provide a way to judge the nature of care provided ZZ Reflect the expectation for the care that should be provided to clients with various illnesses ZZ Reflect professional agreement focused on the minimum levels of acceptable performance ZZ Can be used to legally describe the standard of care that must be met by a provider ZZ May be precise protocols that must be followed or more general guidelines that recommend actions PROFESSIONAL ROLE RESPONSIBILITIES XX Confidentiality ZZ The client’s right to assume that information given to the healthcare provider will not be disclosed ZZ Protected under federal statute through the Medical Record Confidentiality Act of 1995 (S. 1360) ZZ Pertains to verbal and written client information ZZ Requires that the provider discuss confidentiality issues with clients, establish consent, and clarify any questions about disclosure of information ZZ 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 XX HIPAA ZZ The first national comprehensive privacy protection act ZZ Guarantees clients four fundamental rights: Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 17 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. XX The Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009 (Health Resources and Services Administration [HRSA], 2013) ZZ Incentive payments for sharing specific electronic health record (EHR) data ZZ Meaningful use incentives ZZ Electronic health records can improve both individual and population-based health outcomes (Friedman, Parrish, & Ross, 2013). ZZ Electronic health records can improve quality, safety, efficiency, effectiveness, and outcomes (U.S. DHHS, Office for Civil Rights, 2013). XX E-prescribing XX Computerized physician order sets XX Tracking care and avoiding duplication of services XX Telehealth ZZ 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 ZZ Must follow the same standards as care delivered in person ZZ Must be practiced in accordance with international, federal, and state regulatory agency standards ZZ Must include provisions for emergency care of the client ZZ The PMHNP must assure that HIPAA regulations regarding confidentiality and maintenance of the health record are followed. XX Exceptions to guaranteed confidentiality ZZ When appropriate persons or organizations determine that the need for information outweighs the principle of confidentiality ZZ If a client reveals an intent to harm self or others ZZ Information given to attorneys involved in litigation ZZ Releasing records to insurance companies ZZ Answering court orders, subpoenas, or summonses ZZ Meeting state requirements for mandatory reporting of diseases or conditions ZZ Tarasoff principle (Tarasoff v. Regents at the University of California, 1976): Duty to warn potential victim of imminent danger of homicidal clients ZZ In cases of child or elder abuse XX Informed consent ZZ The communication process between the provider and the client that results in the client’s acceptance or rejection of the proposed treatment 18 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition ZZ An explanation of relevant information that enables the client to make an appropriate and informed decision ZZ The right of all competent adults or emancipated minors XX Emancipated minors: Persons younger than 18 years old who are married, parents, or self-sufficiently living away from the family domicile ZZ Elements of informed consent XX Nature and purpose of proposed treatment or procedure XX Risks or discomforts and benefits of treatment XX Risks and benefits of not undergoing treatment XX Alternative procedures or treatments XX Diagnosis and prognosis ZZ Provider must document in the medical record that informed consent has been obtained from the client. ZZ PMHNP is responsible for ensuring that the client is cognitively capable of giving informed consent. XX Ethics ZZ Important aspect of the NP role that deals with moral duties, obligations, and responsibilities ZZ What is right versus what is wrong ZZ Ethical principles that provide foundation and direction for complex decisions: XX Justice: Doing what is fair; fairness in all aspects of care XX Beneficence: Promoting well-being and doing good XX Nonmaleficence: Doing no harm XX Fidelity: Being true and loyal XX Autonomy: Doing for self XX Veracity: Telling the truth XX Respect: Treating everyone with equal respect ZZ 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. Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 19 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. ZZ Important ethical principles in psychiatry XX Clients must be involved in decision-making to the full extent of their capacity (mutual decision-making). XX Clients have a right to treatment in the least restrictive setting. XX Clients have a right to refuse treatment unless a legal process resulting in a mandatory court order for treatment has been obtained. ZZ Ethical dilemma XX Occurs in a situation in which there are two or more justifiable alternatives XX Occurs when the choice is made to promote good XX Which option sacrifices the fewest high-priority values (a harm reduction approach)? ZZ Theoretical approaches to ethical decision-making XX Deontological Theory: An action is judged as good or bad based on the act itself regardless of the consequences. XX Teleological Theory: An action is judged as good or bad based on the consequence or outcome. XX 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 XX Clients have a right to know what is happening during the course of their treatment. XX Providers have an ethical responsibility to disclose medical errors, accidents, injuries, and negative results to clients. XX 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). 20 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition Risk vs. Benefits of Disclosure of Disability Regarding Employment XX 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). XX 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. XX Employers are required to make reasonable accommodations for qualified applicants or employees with a disability. Risk of Disclosure XX Employers may find ways to avoid hiring persons known to have a disability. XX Coworkers may harass or discriminate against persons with psychiatric illnesses. XX Assumption that persons with psychiatric illnesses may be less productive XX May limit an employee’s chance for advancement in career XX Feedback for improvement may not be given to employee because others may at- tribute the employee’s behavior to the psychiatric illness. XX Labeling oneself as “disabled” may affect one’s beliefs or self-image. Benefits of Disclosure XX Able to request reasonable accommodations XX Opportunity to have a job coach come to the worksite and communicate directly with employer XX Employee can involve an employment service provider, employee assistance pro- gram, or other third party in the development of accommodations. XX Easier for employee to come to work during an exacerbation of symptoms XX May help with the recovery process XX Allows coworkers to offer personal support XX May empower another employee to disclose Legal Considerations XX Malpractice insurance ZZ Provides financial protection against claims of malpractice XX Coverage for negligent professional acts XX Coverage for highly technical or professional skills required by health professionals, including NPs ZZ Recommended universally for all NPs ZZ Does not protect NPs from charges of practicing outside their legal scope of practice Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 21 ZZ Provides NPs their own legal representation to advocate for them even if their agency also carries malpractice liability insurance protection ZZ 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 XX A legal, not a medical concept XX A determination that a client can make reasonable judgments and decisions regard- ing treatment and other health concerns XX A person is considered competent until a court rules the person to be incompetent. XX If a person is deemed incompetent, a court-appointed guardian will make health- related decisions for that person. Commitment XX Process of forcing a person to receive involuntarily evaluation or treatment XX Process may differ from state to state XX Basic criteria include ZZ Person has a diagnosed psychiatric disorder, ZZ Person is harmful to self or others as a consequence of the disorder, ZZ Person is unaware or unwilling to accept the nature and severity of the disorder, and ZZ Treatment is likely to improve functioning. XX Involuntary admission ZZ Admission to a hospital or other treatment facility against the person’s will ZZ Clients maintain all civil liberties except the ability to come and go as they please ZZ Amount of time clients can be kept against their wishes varies by state XX Voluntary admission ZZ Admission to a hospital or other treatment facility that a person desires or agrees to ZZ Client maintains all civil liberties ZZ Client consents to potential confinement within the structure of a hospital setting 22 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition ROLES OF THE PMHNP Scholarly Activities XX It is important for NPs to engage in the following scholarly activities: ZZ Publishing ZZ Lecturing or presenting ZZ Preceptorship ZZ Continuing education Mentoring XX A process in which a more experienced NP agrees to guide and support a junior col- league in the role, competencies, and skills XX Requires mutual respect and an interactive process of learning XX Needs involvement by both the mentor and the mentee in the relationship Client Advocacy XX Stand up for clients’ rights and empower them to become their own advocates XX Reduce the stigma of mental illness XX Help clients receive available services XX Promote mental health by participating in one or more of these professional organizations: ZZ American Nurses Association (ANA) ZZ American Psychiatric Nurses Association (APNA) ZZ International Society of Psychiatric Nurses (ISPN) Health Policy XX Advanced practice nurses have a legal and ethical responsibility to be a client advocate. ZZ Participation in local, state, national, and international health policy activities (Buppert, 2012) ZZ Involvement: Testify at a public meeting, lobby, or work with the media to bring awareness to an issue ZZ Phases of policy-making: formulation, implementation, and evaluation (Abood, 2007) Case Management XX A system of controlled oversight and authorization of services and benefits provided to clients Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 23 XX Consists of coordinating care, ensuring quality outcomes, monitoring plan of care, and doing advocacy XX Overall goal is to promote quality, cost-effective outcomes Risk Assessment XX Continuous monitoring for high-risk situations XX Assessing persons for nonhealthy behaviors Risk Management XX Activities or systems designed to recognize and intervene to reduce the risk of injury to clients XX Appropriate interventions implemented to reduce nonhealthy behaviors in clients and high-risk situations XX Recognition and intervention to reduce subsequent claims against healthcare providers Advance Directives XX Durable power of attorney for health care. Also known as healthcare proxy ZZ Legally binding in all 50 states ZZ Designates, in writing, an agent to act on behalf of a person should he or she become unable to make healthcare decisions ZZ Not limited to terminal illness; also covers other aspects of illness, such as making financial decisions during a person’s illness ZZ Should be considered as an aspect of relapse planning for clients with chronic psychiatric disorders XX Living will: Document prepared while client is mentally competent to designate preferences for care if client becomes incompetent or terminally ill ZZ Not legally binding in all states CULTURALLY COMPETENT CARE AND SPECIAL POPULATIONS XX 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 XX 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 XX 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 XX Culture-bound syndromes: Specific behaviors related to a person’s culture and not linked to a psychiatric disorder ZZ Be cognizant of inaccurately judging a client’s behavior as psychopathology when it is really related to his or her culture. 24 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition Cultural Influences and Determinants of Health XX 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 circum- stances of a person’s life: ZZ Social contacts ZZ Fluoride in water ZZ Housing surroundings ZZ Water contamination ZZ Climate ZZ Crime ZZ Altitude ZZ Poverty ZZ Temperature ZZ Transportation ZZ Air pollution 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. XX 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. XX The majority of homeless families are headed by a single parent, usually a woman. ZZ 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. ZZ Teen mothers are at high risk due to lack of education and incomes that older parents possess. Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 25 ZZ Reasons for homelessness: XX Mental illness XX Addictive disorders XX Poverty XX Unemployment XX Inadequate public assistance XX Domestic violence XX Lifestyle choice XX 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 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 inten- sive attention XX 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 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 agri- cultural employment XX Men, women, and children of all cultures 26 Psychiatric-Mental Health Nurse Practitioner Review and Resource Manual, 4th Edition 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, discrimina- tion, 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 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. 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 con- structs 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 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. 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 Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 27 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 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. XX 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 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 computer- ized 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 XX 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 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 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 XX Forensic risk assessment: Protect the public from persons with known mental disor- ders 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) Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 29 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? Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 31 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: 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 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. REFERENCES AND RESOURCES Abood, S. (2007). Influencing health care in the legislative arena. Online Journal of Issues in Nursing, 12(1), 3. Accreditation Commission for Education in Nursing. (2016). Accreditation manual. Retrieved from http://www.acenursing.org/accreditation-manual/ American Association of Colleges of Nursing. (2013). CCNE: Commission on Collegiate Nursing Education. Retrieved from http://www.aacn.nche.edu/ccne-accreditation/why-accreditation American Nurses Association. (2000). Medicare and “incidental to” payment: Coverage of nurs- ing services in hospital outpatient clinics and emergency departments. Washington, DC: Author. American Nurses Association. (2014). Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author. American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Nursebooks.org. American Nurses Credentialing Center. (2015). Psychiatric–Mental Health Nurse Practitioner Certification eligibility criteria (across the lifespan) (formerly known as Family Psychiatric– Mental Health Nurse Practitioner). Retrieved from http://www.nursecredentialing.org/ FamilyPsychNP-Eligibility.aspx American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. American Psychiatric Nurses Association. (2011). APNA Board of Directors endorses APNA/ ISPN Joint Task Force recommendation on the implementation of the ‘Consensus model for APRN regulation: Licensure, accreditation, certification & education.’ Retrieved from http:// www.apna.org/files/public/LACE.pdf Baillargeon, J., Penn, J. V., Knight, K., Harzke, A. J., Baillargeon, G., & Becker, E. A. (2010). Risk of reincarceration among prisoners with co-occurring severe mental illness and substance use disorders. Administrative Policy in Mental Health, 37(4), Brownson, R. C., & Petitti, D. (2006). Applied epidemiology: Theory to practice (2nd ed.). London, Eng.: Oxford University Press. Buppert, C. (2012). Nurse practitioners business practice and legal guide (4th ed.). Sudbury, MA: Jones & Bartlett Learning. Burgess, A. W. (1998). Advanced practice psychiatric nursing. Stamford, CT: Appleton & Lange. Commission on Collegiate Nursing Education. (2016). CCNE accreditation. Retrieved from http:// www.aacn.nche.edu/ccne-accreditation Psychiatric–Mental Health Nurse Practitioner Role, Scope of Practice, and Regulatory Process 33 Cotroneo, M., Kurlowicz, L. H., Outlaw, F. H., Burgess, A. W., & Evans, L. K. (2001). Psychiatric– mental health nursing at the interface: Revisioning education for the specialty. Issues in Mental Health Nursing, 22, 549–569. Delaney, K., Chisholm, M., Clement, J., & Merwin, E. (1999). Trends in psychiatric mental health education. Archives of Psychiatric Nursing, 13(2), 67–73. Donabedian, A. (1988). The quality of care. How can it be assessed? JAMA, 260(12), 1743–1748. Edmunds, M. W., Horan, N. M., & Mayhew, M. S. (2000). Adult nurse practitioner review manual. Washin

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