Challenges and Realities of Teaching Psychotherapy: A Survey of Psychiatric-Mental Health Nursing Graduate Programs
Wheeler, Kathleen
PURPOSE. This study was conducted in order to determine what and how psychotherapy content is taught in graduate psychiatric nursing programs in the United States.
DESIGN AND METHODS. This survey was conducted of 120 psychiatric-mental health nursing graduate programs in the United States in order to determine what and how psychotherapy content is taught in these programs.
FINDINGS. The results of this survey revealed a diversity of programs with a plurality of psychotherapy approaches and models taught. Implications for education, research, and practice are delineated.
PRACTICE IMPLICATIONS. Results provide evidence that further clarity, consensus, and curriculum guidelines are needed for teaching psychotherapy in psychiatric graduate nursing programs.
Search terms: Advanced practice psychiatric nursing, competency, psychotherapy
The completion of the Psychiatric-Mental Health Nurse Practitioner (PMHNP) Competencies in 2003 reaffirmed the importance of psychotherapy as an essential skill for all advanced practice psychiatric nurses (National Panel for Psychiatric-Mental Health NP Competencies [National Panel], 2003). With the competencies delineated and the endorsement of these by the Commission on Collegiate Nursing Education (CCNE) for accreditation, it is clear that all graduate advanced practice psychiatric nurse programs seeking CCNE accreditation must teach these skills. Psychiatric-Mental Health Clinical Nurse Specialist (PMHCNS) programs have taught psychotherapy skills since the inception of this role in 1952 when Peplau developed the first PMHCNS program at Rutgers University. Her initial description of the nurse-patient relationship evolved into the one-to-one relationship, then counseling, and finally psychotherapy (O’Toole & Welt, 1989). Specialists in the field were able to conduct psychotherapy while generalists counseled and conducted nurse-patient relationships.
Numerous challenges have been identified in acquiring the skills and competencies needed for competency in this area (Paquette, 2006; Wheeler & Haber, 2004), not the least of which is defining what psychotherapy content is essential. A related challenge is how to fit this material into a reasonable number of theoretical and clinical hours within the already burgeoning amount of curricular content required for the psychiatric-mental health advanced practice registered nurse (PMHAPRN) programs. This survey was undertaken in order to determine what and how psychotherapy content is taught in advanced practice psychiatric nursing graduate programs in the United States. This survey was completed in 2005 after the PMHNP Competencies were endorsed, and it is important because it reflects a baseline upon which to develop and track future curricular changes for advanced practice psychiatric nursing education.
Survey of Graduate Programs
Design and Methods
The survey was mailed to 120 university/college-based psychiatric-mental health nursing programs from a list compiled from the American Psychiatric Nursing Association (APNA) Web site and APNA Educational Council and a customized list obtained from the American Association of Colleges of Nursing (AACN). A pilot survey that consisted of 20 questions was sent to 5 participant schools via email. Approximately half the questions were forced-choice options and half had room for more narrative responses. Several open-ended questions were also asked. Based on the responses from the pilot schools, several minor changes were made to combine several questions and to clarify and simplify content. The second draft was sent to 120 participant schools via email, with an initial response from 34 schools. A further question was then added regarding whether faculty felt students had achieved competency in psychotherapy upon graduation. This final draft was sent to those schools that had not yet responded, with 29 more responses obtained.
Findings
Of the 120 schools contacted, a total of 68 programs responded, for a response rate of 57%. To begin, faculty were asked to report the types of psychiatric-mental health advanced practice nursing graduate programs they offered; many indicated that they offered several programs. The majority of programs (84%) offered the PMHNP adult program, with the PMHCNS program a close second at 62%; 53% offered a PMHNP family program while 42% offered a child/adolescent PMHCNS program; 38% combined the PMHNP and PMHCNS; 15% offered the dual PMHNP with an adult nurse practitioner or family nurse practitioner program; and 10% had PMHCNS plus either an adult nurse practitioner or family nurse practitioner curricula. We further asked what certification exams their graduates were qualified to take upon graduation (see Figure 1).
There was a wide range for the number of credit hours required for completion of the program (from 24 to 77 credits), with the majority (more than 60%) reporting that 45-55 credits were required. The highest number of credits required was for the PMHNP adult programs, ranging from 40 to 72, and the PMHCNS ranged from 40 to 54 required credits. Postmaster’s programs were 16-32 credits. It should be noted that it was not clear in some cases how the total credits were calculated and what the hour-to-credit ratio was.
One survey question asked how faculty integrated child/adolescent or geriatric content into their program of study, and a follow-up question asked what additional courses were required for their PMHNP family program. Thirty-three programs reported that the PMHNP family programs added additional coursework, as illustrated in Figure 2, with 12 of these specifying the courses added. Open-ended comments to this query demonstrated a diversity of approaches currently in use to create PMHNP family curriculum. For example, respondents reported for PMHNP family programs that content is integrated across the lifespan and that there is no curriculum difference in the adult or family PMHNP, but more child/adolescent clients are included for the family students in the clinical practica. In addition, respondents indicated that there exists a multitude of combinations for integrating populations during clinical, with some programs integrating adult and geriatric content while others explained that the availability of practica sites most often determined the population that students worked with.
Questions relating to how the principles of the therapeutic relationship (therapeutic alliance, empathy, positive regard) are taught revealed that only 2% had a separate course for this content; 70% included this in the individual therapy course; and 62% integrated this content throughout the curricula. Ninety percent taught several models of psychotherapy, while only 4% taught one model only (see Figure 3). In addition to those not commonly cited in Figure 3, other types included self, narrative, gestalt, reality therapy, rational emotive, brief therapy/solution focused, existential, feminist, crisis intervention, motivational interviewing, dialectical behavioral, exposure response prevention, desensitization, supportive, social skills training, stress management, assertive training, conflict resolution, reminiscence/life review, stages of change, Adlerian therapy, eye movement desensitization and reprocessing (EMDR), family therapy, transpersonal/person centered, and Yalom group therapy.
The diversity of approaches to teaching psychotherapy was also reflected in the number and type of textbooks cited as used in the programs. More than 80 different texts were reported as used. The top eight cited as most popular were non-nursing texts (see Table 1). The two nursing textbooks most often used were Advanced Practice Psychiatric Nursing by Shea, Pelletier, Poster, Stuart, and Verhey (1999, now out of print) and Principles and Practice of Psychiatric Nursing by Stuart and Laraia (2005).
With respect to practice sites, preceptors, and practica hours, faculty responses revealed that a diversity of practica sites were used, with many programs tailoring the site to meet the student’s needs or interests as well as geographic exigencies. One respondent said that prescribers were needed, not psychotherapists, and it was difficult to find appropriate psychotherapy sites. In addition to the sites listed in Figure 4, nursing homes, day treatment centers, specialized settings for older adults, prisons, psychiatrists, and other private practice offices were also reported. Credentials of preceptors also varied widely (see Figure 5), with those in the “other” category including doctor of pharmacy, counselor, psychologist, master’s in social work, licensed professional counselor, other master’s-prepared behavioral health providers, and psychiatric rehabilitation counselors. Some respondents noted that for psychotropic medications, psychiatrists or advanced practice registered nurses (APRNs) were utilized, while for psychotherapy, licensed clinical social workers or PMHCNSs were used. Rural areas cited mostly licensed clinical social workers or psychiatrists as preceptors.
Several questions were asked relating to whether there was a specified number of practice hours designated for psychotherapy and what treatment modalities were taught. Fifty percent of the queried programs did dedicate hours toward psychotherapy, while 50% combined both psychotherapy and medical/psychiatric management in practica hours. A range of 500-900 clinical hours were required for the schools’ total programs. A wide range was reported for each modality for those schools that did designate a specified number of practica hours: 50-440 for individual psychotherapy, 30-250 for group therapy, and 10-180 for family therapy (see Figures 6-8). Furthermore, some programs reported that: “The student chooses 2 out of 3 treatment modalities,” “Family was required for PMHCNS only,” “Individual and group were combined,” “Varies according to practice site,” and “Only group hours mandated.”
Virtually no programs required that students be in their own psychotherapy, and several explained that this was because of university restrictions. Faculty did note, however, that psychotherapy is strongly encouraged: “Students are expected to practice mindfulness-based therapies,” and “Group therapy was encouraged.” A last, most revealing question was “Upon graduation, do you believe that your students have achieved competency as a novice psychotherapist?” Only 2 respondents said “no,” 15 said “yes,” and the others offered qualified comments such as: “Very novice,” “For the most part, competency is a stretch,” “Know they have to pursue more training after they finish the program,” “About 60% do,” “Very beginning competency,” “Yes, for individual, not for family or group,” “Clinical experiences limited in our area,” “Most of the time,” “We encourage further training,” “Encourage continued supervision and therapy,” and “Don’t envision a future role as a psychotherapist.”
Discussion
In summary, the results of this survey revealed a diversity of innovative, creative programs with a plurality of treatment approaches taught. The PMH adult programs were most popular, with many programs offering both PMHNP and PMHCNS programs. Only one school offered only the PMHCNS program without the PMHNP, and this may indicate that “free standing” PMHCNS programs may be dying out or that perhaps this is an artifact of those who chose to respond to this survey. Indicators from AACN enrollment data and the American Nurses Credentialing Center data would support the move toward NP education (Duffy et al., 2004). This is particularly noteworthy as the PMHCNS is cited most often as a preceptor. Thus, as the specialty is in transition, there is often placement with one discipline while supervision is conducted by another.
Implications for Education
There are many challenges today in graduate psychiatric nursing programs that mitigate against PMHAPRNs attaining competency in psychotherapy. One challenge for nursing education is how, without increasing the credit load, faculty might design programs that teach requisite psychotherapy skills as well as the essentials that are required of graduate nursing curricula. The reality of competing demands requires programs to devise coursework that can be completed in a reasonable amount of time and with a credit load that allows the program to remain competitive. In addition, students need to be educated in multiple sciences (i.e., psychopathology, neurobiology, psychopharmacology, and psychotherapy interventions for individuals, couples, and groups). This makes it impossible in a short amount of time, usually 2 years for most graduate nursing programs, to attain proficiency in psychotherapy. However, competency must be achieved to meet the core competencies of the PMHNP Competencies (National Panel, 2003).
Clinical Sites
Another current challenge for graduate nursing education is the difficulty of finding clinical sites for psychiatrie graduate nursing students to practice psychotherapy. Students are frequently thwarted in learning even the basics of treatment when the only clinical sites available are those with PMHAPRNs managing medication. With economics driving job descriptions, many settings have social workers conducting psychotherapy while the PMHAPRN most often serves as prescriber. This is cost-effective for the agency or clinic because PMHAPRNs usually earn more per hour than social workers, but it restricts the opportunities for the student nurse-psychotherapist to practice psychotherapy. PMHAPRN students can sometimes work out an arrangement where they can see their preceptor’s patients for psychotherapy while the psychiatric PMHAPRN preceptor manages the medication. However, this is only feasible if the preceptor is competent in psychotherapy and can adequately supervise the student. In addition to the liability issues with this arrangement, space constraints, agency policy, or lack of adequate psychotherapy supervision may prohibit the student from seeing an adequate caseload of patients for psychotherapy. Consequently, most graduate psychiatric nurses are likely to leave their master’s programs with a less than adequate knowledge base in this area and may not feel competent to practice psychotherapy. In this era of decreasing clinical therapy sites for students and competing demands on their time, continued collaboration and innovation are needed.
Core Curriculum Standardized Guidelines
Although the PMHNP Competencies state that the PMHNP “conducts individual, group and/or family psychotherapy” (National Panel, 2003, p. 7), this is a general statement, and standardized guidelines for an PMHAPRN core curriculum incorporating psychotherapy skills have, as yet, not been developed. PMHAPRNs need to further delineate specific indicators for meeting specific psychotherapy competencies. For example, competencies might include: The student is able to establish a therapeutic alliance, or can formulate a psychodynamic explanation, or maintain a treatment frame and boundaries. Then, behaviors and indicators that illustrate the achievement of these competencies need to be identified. In addition, many questions are raised regarding how to incorporate these skills, not the least of which is what models or approaches reflect essential content needed for a beginning psychotherapist. Should only one or two models of psychotherapy be taught for depth instead of breadth? Standardized guidelines delineating essential content that meet specific competencies would bring some pedagogic consistency.
Consistency in Programs
The problem of achieving consistency in required psychotherapy competencies multiplies in the PMHNP family programs. Based on the survey, there is considerable confusion around what the PMHNP family curriculum should emphasize. Some educators see this as a lifespan curriculum, while others a family-centered program. How the student will learn psychotherapy techniques suitable to specialty populations is not all clear when the boundaries of the population served and the clarity of the role remain nebulous. The number of the PMHNP family programs has doubled in the last 5 years, and currently, approximately 500 PMHNPs hold this particular certification (Delaney, 2007). Thus, these programs have obvious utility, and it would seem that providing guidelines for essential content and curriculum would increase the appeal as well as ensure quality.
Number of Practice Hours
Confusion also exists regarding educational requirements for the PMHNP postmaster’s certification. Some programs require 500+ additional practice hours for the PMHCNS who wishes to sit for PMHNP exams, while other programs require only 120 practice hours. This seems to fly in the face of logic, particularly when an analysis of recent role delineation studies comparing PMHCNS and PMHNP roles found enough commonalities in these roles that a recommendation was made to develop a single psychiatric PMHAPRN exam that would suffice for all APRNs rather than the two separate exams that are currently offered (APNA, 2006). While this move will undoubtedly resolve a decade-long conflict in the specialty, the finding of commonalities in roles does not address the issue of achieving competency in psychotherapy.
Doctorate of Nursing Practice
Another recent change in nursing education that will significantly affect all APRNs is the endorsement of the doctorate of nursing practice by leaders in nursing, the National Organization of Nurse Practitioner Faculty, and the AACN. This new degree is envisioned as a terminal practice degree, is proposed to supplant the master of science in nursing degree for nurse practitioners by 2015, and will include a clinical research focus. Impetus for this shift came from the lack of parity with other healthcare disciplines, the high amount of credits required in current master’s programs’ curricula, the current and projected shortage of faculty, and the increasing complexity of the healthcare system (Dracup, Cronenwett, Meleis, & Benner, 2005).
Debate continues about whether this terminal practice doctorate will enhance or dilute advanced practice. Presently, there are more than 200 programs that are planning doctorate of nursing practice programs, and some have come to fruition; yet there is no standardized curriculum. It is not clear how curricula and program requirements will continue to evolve in order to provide the needed practice expertise for APRN students. In addition, faculty need current expertise in psychiatric advanced practice in order to effectively teach, and concerns have been expressed about whether graduate faculty have greater academic experience than practice experience because academia traditionally rewards faculty who publish and do research. Clinical practice and teaching are often overlooked in promotion decisions so faculty tend to emphasize research over practice, which may not bode well for PMHAPRN faculty expertise in psychotherapy skills.
Implications for Research
Scholarly debate and the development of an overall framework for psychotherapy practice in nursing are needed. A recent textbook by one of the authors (Wheeler, 2008) does provide a framework that anchors psychotherapy approaches in a holistic nursing paradigm. Whether this model for treatment will be adopted and widely used by advanced practice psychiatric nurses remains to be seen. Since 1954 when PMHCNSs started practicing psychotherapy, Peplau’s (1952) seminal book Interpersonal Relations in Nursing: A Conceptual Frame of Reference for Psychodynamic Nursing has remained the dominant paradigm for psychiatric nursing. Since then, the evolution of the role to integrate physical assessment and managing medical problems in psychiatric patients has created boundary and ethical issues that are only beginning to be discussed in the literature (McCabe & Burnett, 2006).
The literature on how psychotherapy is taught is sparse to nonexistent for graduate psychiatric nursing education, and there is a reliance on other mental health disciplines for textbooks. Recent articles in this journal have begun to dialogue on how programs are incorporating the traditional nurse-patient relationship focus with specific techniques for psychotherapeutic interventions (Perraud etal., 2006). More dialogue through journal articles and conferences about how to teach psychotherapy is needed. Increased authorship of textbooks written by nurse psychotherapists is also needed.
As the PMHAPRN role is further defined and psychiatric nursing scholarship continues to evolve, research will be needed in order to determine what models of curriculum are best for teaching psychotherapy. Outcome studies then should follow on the effectiveness of nurses as psychotherapists, with evidence-based protocols and policies developing from these findings. These data then can be used to shape curricular changes.
Implications for Practice
Psychotherapy practice constraints exist that are system issues relating to reimbursement, with many settings marginalizing advanced practice nurses as medication managers who wish to practice psychotherapy. Managed care allows only 15 min for such appointments, which does not allow time to develop a meaningful psychotherapeutic relationship. APRNs may be able to negotiate with the variety of settings employing them to include psychotherapy with medication management as part of their job descriptions. Further clarification of the PMHAPRN role and scope of practice to consumers, employers, and managed care is essential. It is incumbent upon PMHAPRNs to seek ongoing postmaster’s supervision and further certification in psychotherapy through additional education to ensure expertise and proficiency after graduation. Perhaps there should be a required internship prior to psychotherapy practice. Further research might include a survey of those nurse psychotherapists in practice in order to share and disseminate some of the creative solutions colleagues have devised who practice in a variety of settings.
Conclusion
The challenges for the profession are many, not the least of which are the dominant reductionistic biological paradigm, consumer demand for a quick fix, and the influence of powerful pharmaceutical money for research and marketing. Although psychotropic medications have changed the lives of many with serious mental illness, the integration of relationship and psychotherapy skills with psychopharmacotherapy is essential in order to maximize the benefit of medications (Johnston, 2008). Prescribing in a vacuum without the attending relationship skills in the context of a psychotherapeutic relationship marginalizes the nurse as well as the patient.
“The centrality of relationship to healing and the subjective intuitive stance necessary in knowing another person is rooted in qualitative data and is dissonant with the outcome driven, quantitative philosophy of managed care and contemporary biomédical psychiatry” (Wheeler, 2008, p. viii). However, perhaps as we continue to reaffirm the primacy of relationship to our specialty, psychotherapy may move to center stage and the nurse-patient relationship will reassume the relevance and importance of our historical roots. The results of this survey provide a clear mandate for psychiatric nursing graduate education. Clarity of content, curriculum guidelines, and further development of competencies for psychotherapeutic skills are needed. The educational and practice challenges inherent in attaining competency in psychotherapy presents opportunities for our collective professional growth as we continue to collaborate, evolve, unify, and strengthen our specialty.
Acknowledgment. The authors wish to thank the respondents from the 68 schools of nursing who participated in this survey.
References
American Psychiatric Nurses Association. (2006). Update on Certification: Results of the logical job analysis. Retrieved on January 2, 2007, from http://www.apna.org/news/news.html
Delaney, K. R. (2007). Examining the child and adolescent workforce. Journal of Child and Adolescent Psychiatric Nursing, 20(1), 63-66.
Dracup, K., Cronenwett, L., Meleis, A., & Benner, P. (2005). Reflections on the doctorate of nursing practice. Nursing Outlook, 53, 177-182.
Duffy, F. F., Kohut, J. ]., Pion, G. M., Wicherski, M. M., Batment, N., Merwin, E., et al. (2004). Mental health practitioners and trainees. In R. W. Mandersheid & M. J. Henderson (Eds.), Mental health United States, 2002 (Publication No. [SMA] 3938, pp. 327-368). Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
Johnston, L. (2008). Psychopharmacotherapy and psychotherapy. In K. Wheeler (Ed.), Basics of psychotherapy for the advanced practice psychiatric nurse (pp. 249-273). St. Louis, MO: Mosby Elsevier.
McCabe, S., & Burnett, M. E. (2006). A tale of two APNs: Addressing blurred practice boundaries in APN practice. Perspectives in Psychiatric Care, 42, 3-12.
National Panel for Psychiatric-Mental Health NP Competencies. (2003). Psychiatric-mental health nurse practitioner competencies. Washington, DC: National Organization of Nurse Practitioner Faculties.
O’Toole, A. W., & Welt, S. R. (Eds.). (1989). Interpersonal theory in nursing practice: Selected works of Hildegard E. Peplau. New York: Springer.
Paquette, M. (2006). Redefining the education of the advanced practice psychiatric nurse. Perspectives in Psychiatric Care, 42, 213-214.
Peplau, H. (1952). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: G.P. Putnam’s Sons.
Perraud, S., Delaney, K. R., Carlson-Sabelli, L., Johnson, M. E., Shepard, R., & Paun, O. (2006). Advanced practice psychiatricmental health nursing, finding our core: The therapeutic relationship in the 21st century. Perspectives in Psychiatric Care, 42, 215-226.
Shea, C., Pelletier, L., Poster, E., Stuart, G., & Verhey, M. (Eds.). (1999). Advanced practice nursing in psychiatric and mental health care (pp. 297-313). New York: Mosby.
Stuart, G. W., & Laraia, M. T. (2005). Principles and practice of psychiatric nursing (8th éd.). St. Louis, MO: Mosby.
Wheeler, K. (2008). Psychotherapy for the advanced practice psychiatric nurse. St. Louis, MO: Mosby Elsevier.
Wheeler, K., & Haber, J. (2004). Development of psychiatric nurse practitioner competencies: Opportunities for the 21st century. Journal of the American Psychiatric Nursing Association, 10(3), 129-138.
Kathleen Wheeler, PhD, APRN-BC, and Kathleen Delaney, DNSc, APRN-BC
Kathleen Wheeler, PhD, APRN-BC, is Professor,
Fairfield University School of Nursing, Fairfield, CT;
and Kathleen Delaney, DNSc, APRN-BC, is Associate
Professor, Rush University College of Nursing, Chicago, IL.
Author contact: kwheeler@mail.fairfield.edu, with a copy to the Editor: rnary@artwindows.com
Copyright Nursecom, Inc. Apr 2008
Provided by ProQuest Information and Learning Company. All rights Reserved
