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Psychiatric-Mental Health
Nursing Practice
Patricia B. Howard and Doris Greiner
Constraints and barriers to advanced practice psychiatric nursing were
reported by respondents of the Primary Mental Health and Advanced
Practice Psychiatric Nursing survey of certified psychiatric clinical nurse
specialists. Primary data (N = 507) were the qualitative responses to a
survey item about constraints and secondary data were the literature and
theoretical memos. Methodology was based on principles of qualitative
data analysis and procedures for manifest and latent content analysis.
Findings resulted in eight themes that explained both constraints and
barriers to advanced practice: (1) reimbursement, (2) prescriptive authority, (3) admitting privileges, (4) bureaucracy, (5) practice environment, (6)
colleagues, (7) image, and (8) personal. Themes were interpreted within
the context of regulatory, market-based, and inter/intraprofessional constraints and barriers that led to suggestions for organizational and individual strategies for action. The survey was funded by the Society for
Education and Research in Psychiatric-Mental Health Nursing with technical support from the Center for Mental Health Services.
Copyright 1997by W.B. Saunders Company
198
Regulatory Barriers
Safriet (1992) identified the three most significant regulatory barriers to advanced practice in
nursing as unnecessary restrictions on scope of
practice, limits on prescriptive authority, and reimbursement. Based on analysis from a legal perspective, she argues for legislative reform that would
allow advanced practice nurses (APNs) to provide
the health care they are capable of delivering.
Although she restricted her discussion to nurse
practitioners (NPs) and certified nurse-midwives
(CNMs), the arguments she advanced apply to
APPN practice barriers as well. The direct clinical
practices of all advanced practice nurses touch the
perceived overlapping boundaries of medical and
nursing practice. Nurses are consequently subjected to regulatory control that is inconsistent from
state to state. Fortunately, there are some signs that
this may be beginning to change. In the annual
update for nurse practitioners on legislative issues
affecting advanced nursing practice, Pearson (1995)
documented the fact that state legislative practice
restrictions are beginning to break down. In 1994,
no state became more restrictive, and 12 states
added independent prescriptive authority or modified existing statutes to make them less restrictive.
Market-Based Barriers
Malpractice insurance and admitting privileges
are examples of barriers and constraints in this
category. They are not directly created by statute,
although legislation does have beating on them. An
investigation of state practice environments and the
supply of NPs, nurse-midwives, and physicians
prompted one group of investigators (Sekscenski,
Sansom, Bazell, Salmon, & Mullan, 1994) to
conclude that factors other than those they had
identified affected the practice environment in
important ways. Legal status, reimbursement, and
authority to prescribe influenced supply, but they
are far from the whole story. Rather, these investigators concluded that acceptance as professionals by
physicians, inclusion for reimbursement in health
insurance policies, and acceptance by the public
were important determinants of supply at commu-
199
200
METHODOLOGY
This study was part of the Primary Mental
Health and Advanced Practice Psychiatric Nursing
Survey funded by SERPN from 1994 to 1997. The
research project featured triangulation of methods
(SERPN, 1997). Methodology for this study about
constraints to practice was based on principles of
qualitative data analysis (Lincoln & Guba, 1989;
Patton, 1990), a study design that involved procedures recommended for manifest and latent content
analysis (Catanzm'o, 1988) and the constant comparative method (Glaser & Strauss 1967). To
ensure compatibility and consistency with the principles of naturalistic inquiry, criteria for trustworthiness much like those described by Lincoln and
Guba (1989) were established.
For example, the importance of flexibility was
taken into account, yet rules were delineated for
coding, classifying, and quantifying the textual
data that included some data management with the
computer software program Martin (University of
Wisconsin, Madison WI). Simultaneously, investigator roles and boundaries for steps of the research
process that emphasized adequate time for examining and synthesizing the data were agreed on. To
enhance synthesis, protocols were established for a
minimum of three levels of analysis for development of meaningful concepts that accurately depicted the reported constraints. Procedures for both
independent and joint data analysis were developed
because the investigators' differing practice and
research expertise in psychiatric nursing fit the
criteria for investigator triangulation (Kimchi, Polivka, & Stevenson, 1991; Patton, 1991). Peer
debriefing strategies included research team involvement and feedback. Finally, theoretical and methodological memos for audit purposes were developed.
In essence, the plan for trustworthiness was used as
a guide for promoting credibility of the larger study
(SERPN, 1997) as well as this one.
Data Source
Respondents were certified psychiatric clinical
specialists listed by the American Nurses Association Credenfialing Center when data were collected.
Measures taken to ensure confidentiality and anonymity mirrored those taken for the larger study
and in addition included approval by a University
Institutional Review Board. Information about the
sample, survey instrument, and data collection has
been previously reported (SERPN, 1997).
SD
Age
Years worked: basic Psychiatric
nursing
Years worked: advanced psychiatric
nursing
Hours worked per week: primary
setting
334
46.96
6.94
335
16.92
6.80
335
10.79
6.41
336
34.04
11.06
201
Frequency*
Percent
Hospitals
Clinics, Rehabilitation
Solo Independent
Academic
Group Independent
Visiting Nurse Association
Residential Setting
Other
100
78
57
43
32
9
8
9
29.8
23.2
17.0
12.8
9.5
2.7
2.4
2.7
*Frequency missing = 5.
Data Analysis
Data analysis involved coding, classifying, and
conceptualizing all of the textual data for the
Table 3. Position Description in Primary Setting
Position
Frequency
Percent
193
30
28
14
13
10
9
5
4
3
2
30
56.6
8.8
8.2
4.1
3.8
2,9
2.6
1.5
1.2
0.9
0.6
8.8
Reimbursement
Statements about reimbursement formed one of
the largest clusters of data (Table 4). Both general
and specific types of reimbursement were identified. General types of reimbursement were "third
202
Reimbursement
197
Prescriptive
authority
54
Admitting privileges
Bureaucracy
13
81
Practice environment
81
Colleagues
84
Image
36
Personal
30
Sample Statement
Prescriptive Authority
There were 54 statements about Prescriptive
Authority (Table 4). These statements encompassed two areas of concern: (1) legal controls, and
(2) lack of protocols for prescribing medications
when there were no legal controls.
Legal control. In this study, legal control refers
to both complete and partial restriction of prescriptive privilege. Most statements were about complete restriction, and "Illegal to prescribe" was the
most frequent response. Comments about partial
restrictions contained specific information about
the types or classes of drugs that could not be
prescribed. Examples included: "controlled substances," "class III meds," "class IV controlled
substances," and "most drugs used in psychiatric
practice."
Some statements revealed information about a
specific type of control: "must consult and receive
prescriptions from physicians." Other comments
provided an even broader picture of advanced
practice and the prescriptive authority constraint:
"A very limited number of psychiatrists to refer to
for medication management who are able to treat
women with respect, dignity, and safe pharmacology."
of statements included: "hospital does not acknowledge prescriptive privilege of clinical nurse specialist (CNS) at this time"; "at present I am getting
prescriptive protocols through so that I can prescribe in outpatient setting"; and "the procedure is
time consuming and frustrating for me."
No statements disconfirmed patterns about legal
control and lack of protocols, although one statement, "I do not prescribe medication, my choice"
differed from other comments. Other respondents
reported concerns about the importance of psychopharmacology course offerings: "Although my
state recently gave CNSs prescriptive privileges,
the nearest psychopharm course offered is at least a
2 hour drive away."
Admitting Privileges
Only a few statements focused on lack of
admitting privileges (Table 4). However, this category of data was striking because responses
explicitly focused on a single characteristic of the
constraints theme. Admitting privileges--in and of
themselves--constituted a constraint to practice
whether they were controlled by legal or by hospital systems.
Most responses about the admitting privilege
obstacle were statements like: "Hospitals do not
offer admitting privileges," but other statements
provided a broader picture of the obstacle. For
example, one respondent reported:
As a hospital employee, I work under the hospital umbrella
for billing. I can not use my ARNP license because there
isn't enough physician back up or support. I also do not
have admitting privileges. It is frustrating not to be allowed
to utilize the clinical skill and knowledge I have studied
hard for. In private practice, insurance's (sic) will reimburse for ARNP services. But there are still restrictions
regarding admitting privileges.
Bureaucracy
As indicated in Table 4, the theme of bureaucracy was organized around a large cluster of data.
Four characteristics of bureaucracies were embedded in the data cluster. They were (1) organization
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204
caseload, and workload. Examples included: "responsibility is similar to the psychiatrist role w/o
(without) the remuneration"; "lots of responsibility without authority, formal positional power and
or legal ability to provide certain services"; "caseload too large"; and "lay-offs at hospital caused
increased work load for me of a supervisory-type
not yet in my job description."
Limited resources. Responses indicated that
fiscal and human resources were scarce. Limited
fiscal resources were reported in both specific and
general terms. The specific situations concerned
salary and "fee scales." The more general comments focused on global funding issues: "financial
funding concerns as monies dry up, every year
worrying about contracts and grants." Comments
about constraints on human resources included
"limited staffing" and "lack of secretary personnel." Limited fiscal and human resources had
implications for patient care as well as practice
patterns: "difficulty doing direct patient care and
documenting with fast pt. (patient) turnover and
limited staffing."
Paperwork overload. As indicated in the above
response, the quantity of paperwork was a constraining factor in practice. "Paperwork, paperwork,
paperwork" was the single comment of one respondent. Terms like "overwhelming" and "endless"
were used to describe the overload. Specifically,
paperwork was associated with requirements of
"managed care" and Medicaid." In general, the
constraint was best summarized as: "Too much
paperwork which detracts from the joy of helping
patients."
Practice Environment
Respondents spoke less precisely about ways in
which clients themselves and the society in which
we all live are experienced as constraints to practice. The practice environment was described in
terms of the client's economic and health status,
suitable interventions, and pressure to get the job
done.
Clients and interventions. Statements about
economic status included: "many clients have few
resources and many problems to cope with"; "poor
individuals without insurance who do not qualify
for Medicaid"; and "the economic level of patients: housing issues, transportation issues, family
support, overall health." Specific statements about
health status noted: "wide variety in age and
diagnosis," "very ill clients," and "increasing
severity of mental illness in my caseload." Respondents' comments further suggested that certain
interventions may not fit patient populations or that
suitable options for intervention were completely
lacking. Comments included "increasing focus on
brief treatment not suitable for chronic mental
illness" and "difficulty finding treatment options
for chronic alcoholic patients." The overall picture
was summarized by one respondent as: "unclear
mission with too much diversity in patient needs
within the treatment setting."
Time. A society that emphasizes speed, efficiency, and cost containment poses particular challenges to working with these complex economic
and health issues. A constraint for many respondents was "time." Although most respondents
simply entered the word "time" as a constraint,
other expressions included "time--never enough,"
and "I don't have time to do it all." Still others
explained specifically how lack of time influenced
the practice environment. Examples were: "too
busy for good follow-up care," and "time--often
there are several psychiatric patients in a busy
medical ER and there is tremendous pressure to do
the work quickly." The effect of time was also
embedded in comments such as "not enough hours
and energy in a day" and "time, too many ideas and
not enough time."
Colleagues
The theme of colleagues (Table 4) contained the
second largest cluster of data (N = 84). Respondents' comments suggested control issues. For this
study control is defined as lack of support for, or
failure to foster, the functions of advanced practice
nurses. Colleagues identified in the responses were
"physicians" and "other disciplines," which included "mental health providers," "administrative
staff, nonnursing," "LCSWs [licensed clinical social workers]," "psychologists," and "peers" in
nursing. As revealed in the description that follows,
types of constraints were related to specific colleague categories.
Physician-related constraints. Some of the
statements about physician-related constraints were
about the medical system: "lack of recognition of
CNS by physicians," "conservative medical community," and "national medical lobby." Respondents also reported on specific types of medical
systems: "Dept. of psychiatry is not a strong
service and the residents are generally not encouraged to work collaboratively with psych CNS as
Image
Several respondents (Table 4) indicated that the
general public's image of nursing is a constraining
factor because conceptions and impressions about
205
Personal
Although few in number (Table 4), some respondents reported personal constraints. These constraints involved self-regulation and self-limitations. Self-regulation refers to the establishment of
personal boundaries; self-limitations refer to personal characteristics, energy, and health.
Self-regulation. Most self-regulation responses
were about protecting personal lives. One typical
example: "I am unwilling to regularly work evenings or weekends. This constrains the mix of my
caseload as couples and families often require
evening or weekend appointments." A different
self-imposed boundary involved taking a stand
based on a personal ethical decision: "Will not
work with managed care, have not been pursued as
managed care employee and I am too concerned
about ethics of the care they provide for me to
pursue them."
Self-limitations. Most statements about selflimitations concerned lack of "education and experience." Several respondents reported lack of education in networking skills: "My training did not
allow for adequate networking to develop referral
services. As a result, 80% of my patients are very
low income without insurance." Additional education deficits included "training for private practice," "psychopharmacology," "physical assessment," and "education/supervision in rural setting."
Uncertainty about career direction posed a related
form of limitation: "not so clear about where I want
to go from here; find private practice isolating;
206
providing a common set of services has the potential for communicating a powerful and different
message to administrative personnel at all levels of
the bureaucratic system. Nurses who practice in
routine staff level positions within hospitals, yet
identify themselves and their preparation as APPNs, contribute to the confusion regarding who we
are and what services we can offer. This form of
under-utilization seems to be most prevalent within
hospitals. Although primary care settings are not
without bureaucratic barriers and constraints, they
do have the advantage of making autonomous
practice visible. Primary care settings are also less
likely to employ APPNs in positions that do not
require their advanced practice skills.
The ways in which the respondents to the
SERPN survey discussed issues related to colleagues also echoed very old stories in nursing,
even as they suggested specific attainable remedies.
Effective collaborative relationships with physicians and other health care providers are imperative
to effective APPN practice. Models of collaboration that reflect clearly defined practices with
effective therapeutic and cost outcomes do exist
(Saner & Ford, 1995). The numbers must be
multiplied dramatically.
Although personal responsibility for professional relationships is important, cultural and professional realities continue to reinforce physician
control. A serious error is made when nurses
continue to focus only on the personal level and fail
to recognize the larger political issue inherent in
physician control. Naming providers only as "nonphysicians" renders whole groups of potential
providers culturally invisible (Friedman, 1990;
Safriet, 1992, 1994).
Legislation mandating physician supervision of
APPN practice obscures those areas in which
scopes of practice overlap. Multiple groups must
work collaboratively toward development of competency-based practice acts, interdisciplinary education programs, revised payment schedules, and
practice law that allows demonstrably competent
providers to diagnose, treat, and prescribe (Safriet,
1994).
Intraprofessional and personal constraints. To
engage in political action collaboratively, work
within nursing is obvious. Educationally, the set of
APPN standards (ANA Council on Psychiatric and
Mental Health Nursing, 1994) must be used to
guide practice evaluation that show effective clini-
207
Implications
As specialists within nursing, APPNs must make
their services explicit. This imperative pertains
regardless of practice setting. Data from this study
suggest that making exact services explicit is most
vitally needed in inpatient settings. The current
document (ANA Council on Psychiatric Mental
208
ACKNOWLEDGMENT
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Nichols, L.M. (1992). Estimating the cost of undemsing advanced
practice nurses. Nursing Economics, 10(5), 343-351.
Olsen, T. (1996). Fundamental and special: The dilemma of
Psychiatric-Mental Health Nursing. Archives of Psychiatric Nursing, 10(1), 3-10.
Patton, M.Q. (1991). Qualitative Evaluation and Research
Methods. Newbury Park, CA: Sage.
Pearson, L. (1995). Annual update of how each state stands on
legislative issues affecting advanced nursing practice.
Nurse Practitioner, 20(1), 13-51.
Safriet, B.J. (1992). Health care dollars and regulatory sense:
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Safriet, B.J. (1994). Impediments to progress in health care
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