Advanced Practice Psychiatric Mental Health Nursing, Finding Our Core: The Therapeutic Relationship in 21st Century

Perspectives in Psychiatric Care, Nov 2006 by Perraud, Suzanne, Delaney, Kathleen R, Carlson-Sabelli, Linnea, Johnson, Mary E, Et al

TOPIC. Increasingly, students from various professional backgrounds are enrolling in Psychiatric Mental Health (PMH) Nursing graduate programs, especially at the post-master's level. Faculty must educate these students to provide increasingly complex care while socializing them as PMH advanced practitioners.

PURPOSE. To present how one online program is addressing these issues by reasserting the centrality of the relationship and by assuring it has at least equal footing with the application of a burgeoning knowledge base of neurobiology of mental illness.

SOURCES. Published literature from nursing and psychology.

CONCLUSIONS. The PMH graduate faculty believes that they have developed strategies to meet this challenge and to help build a PMH workforce that will maintain the centrality of the relationship in PMH practice.

Search terms: Nurse-patient relations, psychiatric nursing, empathy, therapeutic relationship, education, nursing, graduate

With the help of federal traineeships, the 1960s and 1970s were times of significant growth for graduate programs in Psychiatric Mental Health (PMH) nursing. In these decades, programs were designed to educate PMH Clinical Specialists (CSs) and the course work included a concentration on the one-to-one interpersonal/therapy relationship model (Lego, 1995). This educational focus was formalized by a coalition of PMH graduate program directors who crafted regional curriculum models, all of which contained content on individual therapy and the therapeutic use of self (National Institute of Mental Health [NIMH], 1987). These PMH curricular threads of therapy and the therapeutic use of self were echoed in the 1996 curriculum guidelines for PMH graduate programs that were put forth by the Society for Education and Research in Psychiatric-Mental Health Nursing (SERPN) (SERPN, 1996). At that time PMH nursing "therapy" was undefined, but could be delineated as an amalgam of various schools of therapy and nursing interpersonal models, heavily influenced by Hildegard Peplau (Beeber, 1995). For these decades PMH graduate students learned therapy and were also socialized to appreciate the importance of the relationship and its potential to facilitate positive change. Although debate continued on the extent to which "therapist" should become central to the clinical nurse specialist (CNS) role, the one-to-one relationship remained as a "core modality in PMH nursing" (Beeber, p. 27).

As PMH nursing approached the 21st century, sweeping changes in mental health care delivery (Krauss, 1993), the creation of the PMH nurse practitioner (Delaney, 2005), and the continued strength of the neurobiological paradigm significantly altered PMH graduate curricula (Delaney, Chisholm, Clement, & Merwin, 1999). These forces undeniably moved PMH graduate programs in a positive direction in terms of science, role development, and workforce needs (Bjorklund, 2003). In this paper, we argue that in the creation of PMH-NP curricula the specialty may have inadvertently loosened their traditional PMH mooring in the nurse-patient therapeutic relationship, and moreover, that the shift in emphasis has eroded the core of the PMH advanced practice nursing identity. Here we trace the factors that are seen to contribute to this unanticipated shift, describe how these factors have eroded the profession's core identity, and articulate our program's initial efforts to integrate the essential elements of the nurse-patient therapeutic relationship back into the curriculum.

Changing the Educational Landscape: PMH Relationship Loses Ground

Under the influence of the paradigm shift ushered in by the decade of the brain and the Essentials of Master's Education, PMH graduate programs began teaching the primary care trio of physical assessment, pathophysiology, and pharmacology (Delaney et al., 1999). The market-driven adoption of the primary health care model moved the PMH role away from the traditional therapy model into psychoeducation, brief therapy, and manualized interventions (Haber & Billings, 1995). This paradigm shift was supported by numerous clinical trials that provided evidence of the superiority of combination therapies (medication plus therapy) in the treatment of depression and other mental disorders (Elkin et al., 1989). In practice, psychopharmacology was increasingly utilized either alone or in tandem with focused therapies (Keller et al., 2000). New clinical guidelines, and perhaps decreasing patient confidence in the efficacy of therapy alone, quickened the move toward evidence-based practice (APA Task Force on Psychological Intervention Guidelines, 1995).

The current influence of evidence-based care has increased variation in therapeutic interventions and separated out the how of therapy (how therapist and patient behave toward each other) and the what of therapy (the techniques or interventions used) (Norcross, 2002). A recent survey of PMH graduate programs revealed that most faculty are teaching a variety of methods (the what of therapy) but it is less clear how these faculty are integrating the relationship (the how) with these techniques (Wheeler & Delaney, 2005). Layered over this split on the how and what of treatment are new curriculum guidelines that recommend content and competency development in therapy and in the neurobiological management of patients. A recent survey of PMH-NP programs indicates that therapy content and practicum are now combined with neurobiological management of patients (Wheeler & Delaney, 2005). The content to be imparted to students is vast and growing every day. This has created a challenge for programs aiming to educate practitioners who are capable of distinguishing and practicing more than a hodgepodge of therapy/interpersonal/neurobiological aspects of care.