Archives of Psychiatric Nursing 29 (2015) 4955

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Review Article

A Modern History of PsychiatricMental Health Nursing

Laura C. Hein , Kathleen M. Scharer
University of South Carolina, Columbia, SC

a b s t r a c t
This paper discusses the progression of developments in psychiatricmental health nursing from the 1960s to the
present. The 1960s were a time of shortage of psychiatric APRNs, with legislation expanding the availability of
mental health services. We nd ourselves in a similar time with 7 million new health insurance enrollees, because of the Affordable Care Act (ACA). The expansion of health insurance coverage comes at a time when
some colleges of nursing are closing master's programs in psychiatricmental health, in lieu of the DNP mandate
from the American Association of Colleges of Nursing. Is history repeating itself?
2014 Elsevier Inc. All rights reserved.

In light of the major changes the United States (U.S.) is currently

experiencing in health care because of the Affordable Care Act (ACA)
and integrative of behavioral health with primary care, it seemed an appropriate time to consider where we have been and anticipate future
challenges. Consequently, the purpose of this paper is to discuss the evolution of psychiatric nursing in the United States since the mid-1900s specically related to the advent of formal training of psychiatricmental
health nurses at all levels, and our readiness to provide equitable levels
of mental health care as required by the ACA (United States Government,
2013). A decade by decade approach is used to illustrate how psychiatric
nursing has evolved since the 1950s and then the issue of our preparedness for the ACA will be discussed.

2014). These psychopharmacological changes transformed the care of

some of the most severely ill individuals typically living in long term
mental hospitals. While the anti-psychotic medication did not alleviate
many of the negative symptoms of schizophrenia, it did moderate the
positive symptoms, making patients easier to approach and manage.
Additionally, monoamine oxidase inhibitors (MAOIs) became more
commonplace in the treatment of depression and the rst tricyclic
anti-depressant, imipramine, was discovered and used to treat depression (Lopez-Munoz & Alamo, 2009).

THE 1950S

The 1948 Brown Report made a major impact on psychiatric nursing

in the 1950s. The Brown report written for the National Nursing Council
recommended psychiatric nursing be included in nursing education
(Brown, 1948). Brown's recommendation came from her experiences
with the U.S. Armed Services during the Second World War. During
World War II there were challenges to mobilize sufcient nurses to
care for the injured. This need for nurses continued when the combat
veterans returned home. In particular some men who returned from
the war had need of psychiatric services related to shell-shock, and for
their daily psychotherapeutic needs which are now referred to as
daily psychosocial needs (Brown, 1948). Additionally the Brown Report
advocated for the education of nurses in colleges and universities, the licensure of professional nurses by examination, and that all schools of
professional nursing become accredited. The recommendation to include psychiatric nursing as part of the professional nurses' education
became a requirement for National League for Nursing (NLN) accreditation in 1955 (Nolan & Hopper, 2000).
During this time-frame Peplau's book, Interpersonal Relations in
Nursing (1952) provided the framework for psychiatric nursing both
as a specialty and as part of everyday nursing practice in all areas of
nursing. Peplau rened her theory in 1992 to further discuss the domain
of nursing and to reiterate the importance of the psychiatric nurse in

Life in the 1950s

In the 1950s the United States and NATO were involved in the Cold
War with communist counties. There were arms races to determine
who could develop atomic weapons. School children practiced drills of
hiding beneath their desks in case of nuclear attack. The 1950s saw
the entry of the U.S. into the Korean War until its end in 1953. The
race for space also began with the Russians putting Sputnik into orbit
in 1957 and the USA beginning the Mercury Space program. It was a decade of continued recovery from WWII (Bradley, 2013).
Changes in Psychiatric Treatments in the 1950s
The major psychiatric treatment change in the 1950s was the development of the rst typical antipsychotic medication, chlorpromazine
(Shen, 1999) and the beginning use of lithium for mania (Purse,
Corresponding Author: Laura C. Hein, PhD, RN, FAAN, University of South Carolina,
College of Nursing, 1601 Greene St. Columbia, SC 29208.
E-mail address: Hein@sc.edu (L.C. Hein).
http://dx.doi.org/10.1016/j.apnu.2014.10.003
0883-9417/ 2014 Elsevier Inc. All rights reserved.

The Evolution of Psychiatric Nursing

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L.C. Hein, K.M. Scharer / Archives of Psychiatric Nursing 29 (2015) 4955

prompting change and consequently healing. Peplau consistently

viewed the nurse's role as a builder of interpersonal relationship and
counselor. In 1953 she was both acclaimed and vilied within and outside of nursing for her push for training psychiatric nurses to conduct
therapy. Despite this negative response she still recognized the need
for nurses with advanced training, and in 1955 Peplau developed the
rst master's-level psychiatric nursing program (the clinical nurse specialist or CNS) at Rutgers University (American Psychiatric Nurses Association, 2009; Rutgers University College of Nursing, 2014). None of
these developments occurred without pushback from hospitals, physicians and other nurses. Some of this resistance was secondary to role
change and nancial concerns (Cantor, 2003).
Advanced practice psychiatricmental health nursing began during
the 1950s with clinical nurse specialists (CNS) being the rst advanced
practice nurses (APNs) (American Psychiatric Nurses Association,
2009). Clinical nurse specialists provided a wide range of services including inpatient and outpatient therapy of various types, ran milieu
therapy in inpatient and residential units, provided mental health services in schools, conducted research, provided consultationliaison to
hospital units, and educated patients, families and other health care
providers. Prior to this time, inpatients primarily received custodial
care without substantial psychotherapeutic intervention. While the
number of CNSs was still small, they began inuencing the way nurses
delivered care to their patients.

Medicare was enacted in 1965 (Anderson & Cannova, 1999); this

had important implications for payment for mental health services in
general hospital settings. Because the Medicare legislation included reimbursement for mental health care as part of the law, general hospitals
began increasing the number of psychiatric inpatient beds. In addition,
hospitals began new building programs to meet the standards for the
hospital environments required for Medicare beds, such as air conditioning. As part of these new buildings, the special needs of psychiatric
patients were now considered.

THE 1960S

Life in the 1970s

Life in the 1960s

The decade of the 1960s was one of turmoil within the country.
There was resistance to the draft for the Vietnam conict, the feminist
movement altered the role of women in society and there was more tolerance for free love, drug use and communal living. This decade of acceptance also saw a movement in communities of color for increased
civil rights and culturally appropriate health care (Anderson & Cannova,
1999). The legal system also began to recognize the needs of the mentally ill, reforming commitment hearings and proceedings (Anderson
& Cannova, 1999). In 1961 the Cuban Missile Crisis had the country
quite concerned about a major war with our Cuban neighbor which
lasted until October of 1962 (Goodwin & Bradley, 2011). In 1961, the
U.S. escalated the number of troops participating in the Vietnam conict. Vietnam saw a different type of ghting with children being used
to kill soldiers and whole villages of families being harmed. The conict
in Vietnam persisted throughout the 1960s (Dates & Events, 2014a). In
1963, the country mourned the death of President John F. Kennedy, following his assassination in Texas. The decade ended with the Apollo 11
lunar landing and man walking on the moon (Dates & Events, 2014a).

The Evolution of Psychiatric Nursing

The CMHCA was enacted during a time of nursing shortage which
led Congress to pass the 1964 Nurse Training Act which assisted nurses
to pursue graduate study. These funds provided traineeships for graduate education in psychiatricmental health nursing and community
health (Perraud et al., 2006). Traineeships were also available to support
doctoral education and in the late 1960s the rst doctoral program focused on nursing practice (DNSc) was developed at Boston University
(Robb, 2005).

THE 1970S

In 1973, a cease re in Vietnam was negotiated, followed by the

withdrawal of U.S. troops. This did not end the ghting in Vietnam
and eventually the south part of the country fell to the north part of
Vietnam in 1975. Early in the decade, the anti-war movement disrupted
the lives of young men and resulted in a variety of demonstrations,
including the killing of protesters at Kent State. The U.S. established
diplomatic relations with China in the 1970s. The Watergate political
upheaval occurred in this decade and resulted in the resignation of
President Nixon. The decade ended with the Iranian hostage crisis
(Gillis, 2013).
It was a decade of many advances which included the development
of microprocessors, the oppy disk, MRIs, video games, VCRs, e-mail
and test tube babies. The rst jumbo jets changed air transportation
and recombinant DNA technology led to the development of genetic
engineering. It also brought the rst cases of HIV to the U.S., although initially little was done to combat this problem resulting in
the death of thousands (Dates & Events, 2014c; Gillis, 2013; The
AIDS Institute, 2014).
In the early 1970s, the costs of medical care continued to grow, partly as a result of the Medicare legislation, while the country was in a
major recession. President Nixon attempted to control these costs by
freezing the pay of health care workers and some other groups.

Changes in Psychiatric Treatments in the 1960s

Advancements in pharmacological therapies continued to transform
psychiatric care. The rst benzodiazepine (chlordiazepoxide) was introduced in the 1960s. The availability of this new class of medications
greatly enhanced the ability of nurses to develop a therapeutic relationship with patients (Brown, 1963). Despite these new medications, traditional medical treatments such as electroconvulsive therapy (ECT) and
psychotherapy continued.
At this same time (1963) the Comprehensive Community Mental
Health Centers Act (CMHCA) was enacted and sought deinstitutionalization of the mentally ill and provision of community services to address
their mental health needs. There were several problems with the implementation of the CMHCA such as funding, undeveloped community services for the mentally ill, an ambiguous mission and lack of clarity of
authority (Grob, 2005). Many of these problems remain today especially
in rural America.

Changes in Psychiatric Treatments in the 1970s

In 1977 President Jimmy Carter established the President's Commission on Mental Healththe rst survey of mental health since the
1950s. Unfortunately, the Commission was more ideological and symbolic than practical (Grob, 2005). There were no specic programs
established as a result of the Commission's work.
In 1979 (16 years after the CMHCA) The National Alliance for the Mentally Ill (NAMI) was founded to provide support to and advocacy for persons with severe mental illness. This was the rst national consumer
group in the mental health arena (National Alliance for the Mentally
Ill (NAMI) (NAMI), 2014), a program by and for family members and
those aficted by mental illness. This same year, the rst nursing doctorate (ND) program was developed at Case Western Reserve (Cronenwett
et al., 2011).

L.C. Hein, K.M. Scharer / Archives of Psychiatric Nursing 29 (2015) 4955

The Evolution of Psychiatric Nursing

1971 saw the beginning of a grassroots focus on child mental health
by nurses. In 1971 Advocates for Child Psychiatric Nursing (Advocates)
was founded. The organization later became known as the Association
of Child and Adolescent Psychiatric Nurses (ACAPN). Advocates were
founded to meet the needs of this small sub-specialty group of advanced
practice nurses who felt that their needs and those of their patients
tended to get lost when the child psychiatric nurses were included in
large general psychiatric organizations.
Nurse practitioner (NP) roles began to develop in a number of specialties in the 1970s. However the role developed later in psychiatric
mental health nursing because CNSs were already providing almost all
of the functions NPs proposed to do, except prescribing medications.
THE 1980S
Life in the 1980s
In 1980 President Carter introduced the Mental Health Systems Act,
changing the focus of mental health services to prevention of mental illness. This legislation intended to provide federal funding directly to
local communities where people with mental illness might receive
care. However, it is unknown how effective the Act might have been because in 1981 Congress passed the Omnibus Budget Reconciliation Act
that defunded 80% of the Mental Health Systems Act (Grob, 2005). President and Mrs. Carter continued to support improvements in mental
health care through the Carter Center in Atlanta after the end of the
President's term of ofce.
The decade began with a revolt in Poland against the Soviet Union
and by the end of the decade, the Berlin wall had fallen. The U.S. intervened in Grenada with troops to overthrow the regime and establish a
better environment for the people of Grenada. There were also military
accords with Russia to remove nuclear weapons from Europe (Dates &
Events, 2014a).
During the 1980s more women entered the work force; divorce became more common. Personal computers were within reach of many
families. It was the age of the multibillionaire. AIDS was rst ofcially
mentioned by the CDC in 1981, and by 1989 there were 100,000 documented cases (AIDS.gov, 2014). This is a decade rife with homophobia.
Gay men were dying, and some were calling it the judgment of God
(AIDS Called Punishment, 1986; McGory, 1985). Space exploration continued with re-usable space ships. The Challenger explosion with teacher Christa McAuliffe was watched by millions of school children
(Whitley, 2012).
Changes in Psychiatric Treatments in the 1980s
The rst selective serotonin reuptake inhibitor (SSRI) (uoxetine)
became available in 1987. The late 1980s to late 1990s saw a threefold
growth in the treatment of depression, a growth not observed in other
aspects of mental healthcare (Olfson et al., 2002). Case management
was begun during the 1980s in yet another attempt to control rising
medical costs. Psychiatric patients were included in case management
with general hospital admissions while simultaneously public hospital
admissions for psychiatric disorders were being drastically reduced. Unfortunately outpatient services, coordination of services, and other
types of treatment such as day treatment programs took time to be developed, leaving some people with mental illness no place to obtain
needed services. Grassroots efforts began within and outside of nursing
to meet these unmet needs.
The Federation of Families for Children's Mental Health began in 1989.
This is a family-driven organization for families of children with mental
health problems. The National and State chapters have boards composed of at least 51% family members of children with mental health
problems. This organization seeks to advocate for and support families

51

in need of their services (National Federation of Families for Children's

Mental Health, 2014). NAMI continued to advocate for the needs of psychiatric patients and their families.
The Evolution of Psychiatric Nursing
Several organizations of psychiatricmental health nurses began in
the 1980s. At this time there were sections within American Nurses Association (ANA) for different nursing specialties. However, several
psychiatric-nursing specialties did not feel that their needs were being
addressed by the general psychiatric nursing section at ANA. This was
particularly a problem for advanced practice nurses. The Society for Education and Research in PsychiatricMental Health Nursing (SERPN) was
founded in 1986; the prior name of SERPN was the Council of Deans
and Directors of Graduate Programs in PsychiatricMental Health Nursing,
founded in 1983 (International Society of PsychiatricMental Health
Nursing, 2014). The American Psychiatric Nurses Association (APNA)
was founded in 1986 to ll the professional needs of the psychiatric
mental health nurse at the registered nurse level.
THE 1990S
Life in the 1990s
1990 saw the enactment of the Americans with Disability Act (ADA)
(29 U.S.C. 1630). Mentally and physically ill Americans could no longer
legally be discriminated against in housing, employment or public services. Although disabled persons had protection if federal employee's
since 1973 (29 U.S.C. 794), the majority of Americans did not enjoy
this benet until 1990.
The cold war ofcially ended with the demise of the USSR in 1991.
However, unrest in the Middle East led to the Kuwaiti war. The U.S.
also participated in peace keeping missions in Bosnia and Yugoslavia
and intervened in Haiti to topple the regime there (Whitley, Bradley,
Sulton, & Goodwin, 2011).
The Internet was born. Technological advances continued to drive
the country forward to the screen age with cell phones and laptops. It
was a decade of mergers in business. It was also a decade of increasing
violence with the Oklahoma Federal Building bombing and the Columbine shooting (Dates & Events, 2014b; Whitley et al., 2011).
Changes in Psychiatric Treatments in the 1990s
Psychiatric treatments continued to evolve with the ongoing development of psychiatric medications such as atypical anti-psychotics and
new anti-depressants and anxiolytics. The atypical anti-psychotics
helped combat both the negative and positive symptoms of schizophrenia. Selective serotonin reuptake inhibitors helped relieve depression
with less potential for lethal overdoses and several of these had great
anxiolytic properties, allowing both depression and anxiety disorders
to be treated with one medication. President Bush declared
19902000 the decade of the brain (Bush, 1990). Signicant scientic
advancements in understanding how the brain functioned to regulate
emotions and control behavior ensued. Psychiatric nurses continued
to work with patients in a wide variety of settings.
The Evolution of Psychiatric Nursing
A study in the mid-90s found that the predominant role of psychiatric staff nurses was counseling patients (Morrison, Shealy, Kowalski,
LaMont, & Range, 1996), a role Peplau supported in the 1950s. Simultaneously, there was a debate within nursing about the continued role of
the clinical nurse specialist (CNS) vs. the nurse practitioner (NP)
(Delaney, Chisholm, Clement, & Merwin, 1999). Others considered the
merger of these roles into various NP roles (Bjorklund, 2003). In the
early 1990s the American Nurses Credentialing Center (ANCC) allowed

52

L.C. Hein, K.M. Scharer / Archives of Psychiatric Nursing 29 (2015) 4955

four primary types of NPs (adult or family NPs treating general health
problems in psychiatric patients; adult or family NP treating psychiatric
patients for their mental illnesses; CNS treating psychiatric illness and
the psychiatric NP treating psychiatric illnesses) to take the Psychiatric
Mental Health NP (PMHNP) or PsychiatricMental Health CNS
(PMHCNS) exam (Bjorklund, 2003) for continued certication. This
issue was revisited in 2005 (Rice, Moller, DePascale, & Skinner, 2007)
The 1990s saw confusion among patients and non-nurse providers
about the different roles and credentials within psychiatricmental
health nursing. Additionally, there were variable laws governing APN/
physician working relationships across states based on state Nurse Practice Acts. In some states psychiatric CNSs practiced with greater autonomy than other specialties, further confusing the public and nonpsychiatric providers.
In the spring of 1995, Carolyn Lewis, who was the Executive Director
of ANCC, noted that there were psychiatric NPs in eight states who were
unable to get reimbursement due to State Board of Nursing regulations
related to advanced practice nurses. ANCC determined that this issue
could best be addressed through certication examinations for psychiatric NPs. However, the psychiatric nursing organizations were quite
concerned about this plan and held a joint meeting of the various psychiatric nursing organizations. These professional organizations perceived that the new exams would undermine existing CNS practice.
ANCC still believed this was the best solution. There were concerns
about the validation of the Psych NP test, which was viewed by some
as primarily a CNS exam with some family nurse practitioner content.
APNA was also concerned about the proliferation of exams and decided
to initiate its own credentialing process with a single exam. The debate
about CNS vs. psych NP occurred within nursing organizations and is
reected in the literature of the late 1990s, for example, articles by
Howard and Greiner (1997), McCabe and Grover (1999), and Pasacreta,
Minarik, Cataldo, Muller, and Scahill (1999)).
In the late 1990s, The American Nurses Associations and representatives from APNA and ISPN revised the Scope and Standards of Psychiatric
Mental Health Nursing (American Nurses Association, 2000). The work
group had many discussions about the issue and determined that there
was one overarching priority for advanced practice in psychiatric nursing
practice which was the provision of primary mental health care to patients seeking mental health services in a wide range of delivery settings
(American Nurses Association, 2000, p. 18). The Scope and Standards of
PsychiatricMental Health Nursing were considered to be the basis upon
which the ANCC certications were developed. The ANA work group
hoped that the statement about there being only one priority for
practice would aid ANCC in developing one exam for both CNSs and
Psych NPs.
Nursing doctorate (ND), and doctor of nursing practice (DNP)] programs expanded over time, although currently less than 1% of all nurses
have doctoral degrees (HRSA, 2013). Some early adopters of the practice
doctorate in the 1990s called the degree a nursing doctorate, or other
similar terms. After a few years, the nursing profession agreed that the
doctor of nursing practice should be the degree for the practice doctorate, to avoid confusion. It is unknown how many DNP nurses specialize
in psychiatricmental health nursing. But even if we knew how many
nurses with DNPs specialized in psychiatric nursing, we might not
know how many were available to actually see psychiatric patients in
practice. Many universities seek doctorally prepared faculty for clinical,
tenure-track and research faculty appointments drawing these experts
away from the clinical setting. The American Association of Colleges of
Nursing (AACN) call for the DNP as the advanced practice standard
has sent experienced clinicians back to school and out of the clinical
areaat the same time we are called to provide more mental health
and addiction services (United States Government, 2013).
In 1994, the International Society of Psychiatric Consultation
Liaison Nurses formalized their organization, which had existed informally for some years. This organization was composed of psychiatric
clinical nurse specialists who provided consultation for persons in

non-psychiatric hospital units who were experiencing psychosocial reactions to their health problems.
The International Society of PsychiatricMental Health Nurses (ISPN)
was formed in 1999 through the merger of three psychiatric nursing organizations: the Association of Child and Adolescent Psychiatric Nurses
(ACAPN); the Society of Education and Research in PsychiatricMental
Health Nursing (SERPN) and the International Society of PsychiatricConsultation Liaison Nurses (ISPCLN) (Bjorklund, 2003). Each of these
organizations had a component that focused on advanced mental health
nursing practice and mental health research. Adult and Geropsychiatric
Mental Health Nurses (AGPN) was later added as a division of ISPN. The
combined focus of the divisions within ISPN is the advanced practice
psychiatricmental health nurse (International Society of Psychiatric
Mental Health Nursing, 2014).
THE 2000S
Life in the 2000s
President George W. Bush signed the New Freedom Act in 2001
which focused on insuring that Americans with disabilities, including
serious mental illnesses, had more opportunities for living within mainstream America. The bill included provisions for greater educational access, adequate transportation and employment opportunities. The
mechanisms to improve the status of people with disabilities included
increasing access through development of assistive technology, increasing educational resources to allow persons with a disability to complete
whatever level of education they desired to prepare for future employment, and promoting full access to community life, for example with
improved transportation opportunities. This act also resulted in stimulating the economy as well as improving the lives of persons with disabilities by providing economic investments for necessary technology
and other services (The White House, 2001).
It was on September 11, 2001 that the airplane bombings of the
World Trade Twin Towers, the Pentagon, and an attempt on downtown
Washington D.C. occurred. This was the rst time foreign nationals had
terrorized on American soil (Dates & Events, 2013). It shook the entire
nation and people were anxious about repeat attacks for many months.
The U.S. responded by invading Iraq and later Afghanistan. The Middle
East has continued to be a center of unrest with various countries undergoing revolutions or wars.
We also experienced a serious economic recession during the 2000s
due to the collapsing of many banks, with associated defaults on loans
and mortgages (Wright, 2014). In the 1990s many families seriously
overspent and were unable to cope with high debt when the recession
hit in the 2000s. In addition, many families lost one breadwinner to unemployment who had been counted upon to help pay the bills. Some
families just had to abandon their homes because they could not nancially manage their debt. Many seniors saw their investments, meant to
last a lifetime decimated. Interest rates fell to an all-time low. The economy is slowly recovering (Jakab, 2014; Wright, 2014).
In 2009, Barack Obama was inaugurated as the 44th President. In
2010, he signed into law the Affordable Health Care (ACA) legislation
which had the potential to increased access to health care, included
more preventative services, and helped states fund these programs
with increases to Medicaid. The provisions of the law were enacted
slowly with some provisions not being available until 2015 such as compliance of grandfathered insurance policies with ACA regulations.
Changes in Psychiatric Treatments in 2000-to-2014
Research in 2005 comparing the prevalence of mental disorders in
the 1990s to the 2000s found no difference in the prevalence of mental
disorders, but did nd a 12% increase in treatment of mental disorders
(Kessler et al., 2005). Over half of these treatments were provided in primary care settings. Ironically, it was the ANCC who had curbed the

L.C. Hein, K.M. Scharer / Archives of Psychiatric Nursing 29 (2015) 4955

practice of the PMH CNS/NP in primary care settings in the early 1990s,
as discussed in the previous section. The early 2000s was also a time of
Medicaid reduction, something that disproportionately impacted the
mentally ill (Rowland, Gareld, & Elias, 2003). The duration of hospital admissions were shortened, units were closed and psychiatric nurses were
downsized or moved to other areas of practice (Sabella & Fay-Hillier,
2014). After many years of discussion and planning, the PMHNP exam
went into effect in 2001. This exam limited the practice of the PMHNP
to the provision of psychiatricmental health careprimary care was
now deemed beyond their training (Bjorklund, 2003). What had not
changed was the authority of psychiatric NPs in all states to prescribe
(National Council of State Boards of Nursing, 2014a). CNS's were able
to prescribe in only 39 states (National Council of State Boards of Nursing, 2014b). The confusion between psychiatric CNS and NP roles
and proliferation of APRN credentialing examinations prompted a logical
job analysis by APNA and ANCC in 2005 (Rice et al., 2007). The job analysis found that of the 335 tasks felt to be essential to practice within
6 months of certication for both CNSs and NPs, less than 1% (3
tasks) differed between the roles (Rice et al., 2007). The panel voted
that the same certication exam be administered to both PMH-CNSs
and PMH-NPs.
In 2008 the Mental Health Parity and Addiction Equity Act was signed
into law as sections 511 and 512 of the Tax Extenders and Alternative
Minimum Tax Relief Act of 2008 [Pub. L. No. 110343 (2008)]. This law
prohibits insurers from charging more for mental health than physical
health services if both are in the insurance plan. The law does not require that insurers cover mental illnesses/substance abuse. But if both
are covered in an insurance plan, the coverage must be equitable. Although this was progress toward better care, this law clearly left a
very large loophole for denial of care.
The World Health Organization (WHO) recommends movement toward mental health services in general hospitals and the inclusion of
mental health care in the primary care setting (World Health Organization, 2007b). Additionally, the WHO stresses the importance of nurses
in care, decision-making and mental health advocacy and policy
(World Health Organization, 2007a).
The Evolution of Psychiatric Nursing
In 2008 the AACN released a report dening standards for APRN education, practice and regulationthe LACE document (AACN, 2008).
After some discussion, APNA and ISPN both supported the resolution
that the PMH-NP would be the entry-level APRN psychiatric nursing degree in 2010 (Delaney, 2011). Some psychiatric nurses felt
disenfranchised by the LACE document, particularly CNSs who had a
long history of independent practice. The LACE document is to be implemented by 2015 (American Association of Colleges of Nursing, 2008).
After the LACE document was accepted, ANCC announced that it
would no longer provide the CNS exams for adult and child psychiatric
nursing. Therefore, while current CNSs could maintain their certication
via the continuing education requirements, no new psychiatricmental
health CNSs would be credentialed.
WHERE WE ARE GOING
October 2013 to January, 2014 the Affordable Care Act (ACA) (Pub.L.
No.111-149) began the last phase of implementation, signing up individuals for health care insurance plans if they were uninsured or underinsured. The ACA was designed to extend the Mental Health Parity and
Addiction Equity Act (United States Government, 2013). Despite the
Mental Health Parity Act, insurers commonly placed benet limits on
psychiatric care as well as lifetime maximums on benets. Psychiatric
conditions were also deemed preexisting conditions that could disqualify one from obtaining insurance. The ACA requires insurers to provide
parity of services between medical and mental health/substance abuse
services. Additionally, it prohibits yearly or lifetime limits on any

53

healthcare, including mental health/substance abuse coverage (U.S. Department of Health & Human Services, 2014). It is anticipated the expanded access to mental health and substance abuse services
facilitated by the ACA will increase the demand for PMH NPs and CNSs
(Delaney, 2011; Pearlman, 2013).
As in the 1960s there is once again a call for more PMH nurses to be
trained. However, the training will need to accommodate an insurance
governed environment prevention, treatment and creative efforts leading to recovery (Delaney, 2011). These are the same things mandated in
the 1980 Mental Health Systems Actbut never implemented due to
Congressional defunding.
Although a multitude of medications are now available to assist the
mentally ill, cost continues to be a consideration. Additionally, limited
availability of mental health professionals in network is a barrier to
treatment. The Affordable Care Act includes parity between medical
and mental health services. However, the ACA is couched within a free
market model which allows insurance companies to stipulate for
which providers they will pay. Individuals in rural areas may have substantial difculty nding an in-network mental health provider near
their home. The provision of services in rural areas remains a problem because of the limited number of providers in rural areas. In
some cases, patients may need to drive several hours to receive psychiatric services. This can present serious hardships in terms of work
and transportation.
Children's services particularly suffer from an inadequate supply of
providers educated to work with this population. Mental health problems in youth occur in the same percentages as in adults, aficting approximately 20% of the population (Bagalman & Napili, 2014).
Additionally most of the children who suffer from a mental illness will
continue to deal with that illness throughout their life. Children with
mental illness grow up to be adults with mental illness. In children,
however, the consequences of mental illness can affect normal growth
and development in many areas including poor social development,
missed learning in school which may not be recouped at a later date,
and disruptions in the family, including among siblings. Access to care
can be related to the caregiver's ability to provide health insurance
for the child. Three point four million children had no insurance and
7.6 million were not insured for at least part of the year. Additionally
14.1 million were underinsured. Twenty-nine million children were enrolled in Medicaid while 7 million more were enrolled in the Children's
Health Insurance Program in 2009 (Kogan et al., 2010). Children without mental health insurance were less likely to receive treatment than
those with insurance (DeRigne, Portereld, & Metz, 2009). In 2004,
64% of youth who needed mental health services did not receive them
(Merikangas et al., 2011). A shortage of providers of mental health services for children and the stigma of having a child with mental health
problems contribute to many children not receiving services required
for their mental health problems.
While more individuals may have insurance coverage for mental
health problems due to the Affordable Care Act the lack of availability
of providers may impair the provision of mental health services. However, the integration of mental health services in primary care holds
promise for individuals receiving services sooner with the potential
for interrupting negative behavioral patterns which can develop when
mental health problems are not treated in a timely fashion. For example,
attention decit hyperactivity disorder (ADHD) affects about 7% of children and typically becomes apparent in preschool children. ADHD can
be readily treated with a variety of medication. Left untreated, ADHD
can affect cognitive development and learning capacity and can result
in behavioral problems such as oppositional deant disorder (Baker,
Neece, Fenning, Crnic, & Blacker, 2010). With preschool children being
seen by primary care providers for normal childhood care, better integration of mental health services in the primary care ofce will, hopefully, result in earlier identication and treatment of the ADHD, thus
preventing other complications which might otherwise occur. Thus
the new model of integrating psychiatric services into primary care

54

L.C. Hein, K.M. Scharer / Archives of Psychiatric Nursing 29 (2015) 4955

has the potential to improve mental health services for many with earlier intervention and treatment.
Over the last 60 years psychiatric nursing has adapted to changes in
legislation impacting access to care. The early 1960s saw a shortage of
master's prepared psychiatricmental health nurses and the federal
government responded with legislation designed to encourage education of nurses. Many of the nurses trained under that program are
nearing retirement or leaving practice to return to school to pursue a
DNP, further depleting the number of APRN providers in practice. One
percent of nurses possess a doctorate, something the AACN has said all
APRNs should have by 2015 (American Association of Colleges of Nursing, 2004; HRSA, 2013). As noted by Fontaine and Langston (2011) the
AACN DNP target date of 2015 seems to have been determined outside
of the foreseeable healthcare changes that we are now facing. Psychiatric mental health nursing is among the hardest hit with the LACE changes in certication and, consequently, training requirements (American
Association of Colleges of Nursing, 2008; Delaney, 2011). We do not
know the number of people who will seek mental health care under
the ACA. We do know that as of April 1, 2014, 7 million more people
have access to mental health care (Carney, 2014), and approximately
25% will require mental health care (Reeves et al., 2011). We are not
ready at this point but, hopefully, we can mobilize quickly to increase
the number of psychiatric generalists and APRNs to help provide care
for individuals needing mental health care.
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