ENHANCING CHILD AND ADOLESCENT CONTENT & CLINICAL TRAINING IN ADVANCED PRACTICE PSYCHIATRIC NURSING PROGRAMS: A JOINT WORKSHOP FROM THE APNA CHILD/ ADOLESCENT COUNCIL AND THE APNA GRADUATE EDUCATION COUNCIL National Organization of Nurse Practitioner Faculties (NONPF): 2016 Survey of PMH NP Programs (Vanderhoef & Delaney, in press) Current state of PMH NP graduate education Particular focus on two challenges: Alignment with APRN Consensus Model (lifespan curriculum) Suggested transition of APRN education to the Doctor of Nursing Practice (DNP) Presenters: Session #4022 Jason Earle PhD, RN, PMHNP-BC Erin Ellington, DNP, RN, PMHNP-BC Pam Lusk, DNP, RN, PMHNP-BC, FAANP The presenters, Jason Earle, Erin Ellington, Pam Lusk have no financial conflicts of interest to disclose NONPF 2016 Survey of PMH NP Programs: Results Program Descriptors (Vanderhoef & Delaney, in press) 118 program directors 75 responded (64% response rate) Lifespan curriculum all but 1 program (transitioning) Total student enrollment: 2,802 Average number of PMH NP graduates/program 12 (1-50) MSN PMH NP post-graduation position: 96% clinical DNP post-graduation position: 46% clinical (remainder applying for dual roles practiceacademic or practice-administration) Learning Outcomes Discuss the basic knowledge, skills, and attitudes needed by the PMHNP to provide evidence based psychiatric mental health care to children and adolescents. Identify various child/adolescent teaching strategies and clinical training opportunities that can be employed in PMHNP programs Create a forum where teaching strategies for child/adolescent content and PMHNP learning opportunities can be shared. NONPF 2016 Survey of PMH NP Programs: Results Curriculum and Clinical Practicum (Vanderhoef & Delaney, in press) Regulatory Requirement: Classroom curricula and clinical practica across the lifespan Difficulty finding child placements and preceptors 2 programs have closed; 1 new program being developed Regulatory Requirement: Education in 2 psychotherapy modalities (individual, family, group) 10 programs offer separate theory of psychotherapy course 38 programs offer separate family therapy course Psychotherapy content frequently integrated into other courses 53 programs require psychotherapy clinical practicum hours (similar to 2008 finding: 50%) Lusk 1
References Vanderhoef, D. M. & Delaney, K. R. (in press). National Organization of Nurse Practitioner Faculties: 2016 Survey of Psychiatric Mental Health Nurse Practitioner Programs. Journal of the American Psychiatric Nurses Association. More In Depth Teaching on the Common Psychiatric Disorders Neuropathophysiology: A Lifespan Approach Psychopharmacology Major Psychopathological Disorders Psychiatric Assessment Across the Lifespan Evidence Based Treatment Group Therapy and Complex Care (Pediatric ADHD, Anxiety, Depressive, and Disruptive Behavior Disorders) DNP Clinical Practica (Integration into Clinical Practice) Rush University College of Nursing JASON EARLE PHD, PMHNP BC JASON_EARLE@RUSH.EDU Progressively Deepening Knowledge Through a Sequence of Courses Neuropathophysiology Pediatric Anxiety Neurocircuity Emotion Generation Circuit Emotion Regulation Circuit Psychopharmacology Pediatric Anxiety Molecular/Cellular Processes Neurotransmitters Receptors Signaling the Nucleus Evidence Based Treatment Pediatric Anxiety and Development Dan Siegel s Interpersonal Neurobiology Perspective Mind Brain Relationships Overview of Rush s Psych DNP Population/Role Cognates and Practica Curriculum Neuropathophysiology: A Lifespan Approach Psychopharmacology Major Psychopathological Disorders Psychiatric Assessment Across the Lifespan Evidence Based Treatment Group Therapy and Complex Care DNP Clinical Practica University of Missouri-Kansas City Erin Ellington, DNP, RN, PMHNP-BC PMHNP Track Coordinator ellingtone@umkc.edu Lusk 2
UMKC PMHNP Program 53 credit hours 660+ psychiatric clinical hours Full time, part time, post MSN Seamless entry to DNP if desired 4 core psychiatric courses (16 hrs) Didactic & clinical Full lifespan Enhancing Child and Adolescent Content Pediatric Behavioral Health Integration Adolescent SBIRT Cognitive Behavioral Therapy Clinical Training Sites Child and Adolescent Content Reading Case studies Discussion board Exam questions Lectures Clinical training Therapy & medication management Pediatric Behavioral Health Integration Didactic Pediatric primary care Advantages/disadvantages Collaborative Care vs Integrated Care SAMHSA Levels of Integration and Competencies http://www.integration.samhsa.gov/ Case examples Clinical training Enhancing Child and Adolescent Content Grant HRSA Behavioral Health Workforce Education and Training for Professionals Develop and expand the substance abuse and mental health workforce who will focus on children, adolescents, and transitional age youth Emphasis is on prevention and clinical intervention Adolescent SBIRT This work supported by grant G02HP27985 from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration http://www.nattc.org/regional centers/content.aspx?rc=midamerica&content=stcustom5 Lusk 3
Adolescent SBIRT Clinical Training Site Local Kansas City sites Inpatient Outpatient Residential Primary care Distance sites Student led search; faculty assisted recruitment Cognitive Behavioral Therapy Workshop: 8 hour training session with an Beck trainer Lecture, video, roleplays, Q&A CBT basics: cognitive model, cognitive case conceptualization, session structure, treatment Emphasis: depression and anxiety disorders Cognitive restructuring, exposure exercises for anxiety, and behavioral activation for depression Population: adolescent, transitional age, young adult Considerations: brief CBT services & E/M add on Future Plans Enhanced pediatric psychopharmacology modules Pediatric telepsychiatry didactic and experiential training Educational integration with PNP students Expand CBT for younger children, play therapy, and family therapy Child/adolescent content for Adult PMHNP Cognitive Behavioral Therapy 1 hr initial assessment on a transitional age standardized patient Complete the Beck Cognitive Case Writeup (Beck, 2011) Overwhelmingly positive student feedback Increased understanding of and confidence in their ability to provide CBT Some interest in post graduation training in CBT Students were better equipped to participate more effectively in their psychotherapy preceptorships References Beck, J. (2011). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press. Heath B, Wise Romero P, and Reynolds K. (2013, March). A Standard Framework for Levels of Integrated Healthcare. Washington, D.C.: SAMHSA HRSA Center for Integrated Health Solutions. Hoge M.A., Morris J.A., Laraia M., Pomerantz A., & Farley, T. (2014). Core Competencies for Integrated Behavioral Health and Primary Care. Washington, DC: SAMHSA HRSA Center for Integrated Health Solutions. Mid America ATTC. (n.d.) Screening, Brief Intervention and Referral to Treatment (SBIRT) Resources. Retrieved from http://www.nattc.org/regional centers/content.aspx?rc= midamerica&content=stcustom5 Lusk 4
ANA Scope of Practice (2014) Faculty Delivered Clinical training in Psychotherapy for PMHNP students: CBT for Children and Adolescents ONLINE, IN CLASS & HYBRID PROGRAMS PAM LUSK, DNP, PMHNP BC, FAANP PROFESSOR, COORDINATOR PMHNP PROGRAM EASTERN KENTUCKY UNIVERSITY Standard 5F. Psychotherapy The Psychiatric Mental Health Advanced Practice Registered Nurse conducts individual, couples, group and family psychotherapy using evidence based psychotherapeutic frameworks and nurse patient therapeutic relationships. Objectives: Discuss the need for PMHNP students to have clinical training in psychotherapy modalities, including the opportunity to develop psychotherapy skills through direct supervised experiences as core content in PMHNP programs. Identify the basic competencies (knowledge, skills, and attitudes) in psychotherapy (cognitive behavioral therapy and group psychotherapy) that are the basis for clinical training of PMHNP students Describe strategies for delivery of clinical training in psychotherapy in PMHNP programs, including online, in class, or hybrid delivery. Identify teaching resources and student evaluation tools / outcome measures for clinical training in psychotherapy in PMHNP programs. ANCC PMHNP Board Certification Exam eligibility requirements: Physical assessment, pathophysiology, pharmacology Content in: Health promotion and/or maintenance Differential diagnosis and disease management, including the use and prescription of pharmacologic and nonpharmacologic interventions AND clinical training in at least two psychotherapeutic treatment modalities. GAP To be eligible to sit for the ANCC board certification exam, PMHNP students are required to have clinical training (didactic and experiential) in 2 forms of psychotherapy. Graduate faculty are challenged to make psychotherapy training and clinical skill practice available for all their specialty students. Brick & Mortar students: Lack of preceptor therapists Training Institutes Online Students: Diverse geographical areas Graduate Programs for Advanced Practice Nurses Our Fourth P Physical Assessment Pharmacology Pathophysiology PSYCHOTHERAPY Lusk 5
Competencies for Psychotherapists Generic Therapeutic Competencies The competencies needed to relate to people and to carry out any form of psychological intervention. Roth, A. & Piling, S. (2008). Using an evidence based methodology to identify the competencies required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioral and Cognitive Psychotherapy. 36, 129 147. CBT with Children & Adolescents Group Therapy An 8 week clinical training module has been developed and delivered that provides knowledge and skill practice for PMHNP students in psychotherapy. The module is competency based teaches psychotherapy knowledge, skills, and attitudes while providing experience in group psychotherapy and cognitive behavioral psychotherapy with children and adolescents. Data: PMHNP student post clinical training evaluations have been collected and are being analyzed from groups of PMHNP students representing the 6 cohorts. Online COPE Training and online group experience 7 weeks Hybrid In Person COPE Training and online group experience 7 weeks In Class COPE Training and brick and mortar COPE groups with faculty, face to face Eastern Kentucky University, St. Francis University, University of Arizona University of California, San Francisco, Vanderbilt University Basic Therapeutic Competencies Knowledge and understanding of mental health problems Knowledge of, and ability to operate within professional and ethical guidelines Knowledge of a model of therapy, and the ability to understand and employ the model to practice Ability to engage client Ability to foster and maintain a good therapeutic alliance, and grasp the client s perspective and world view Ability to deal with emotional content of sessions Ability to manage endings Ability to undertake generic assessment (relative history and identifying suitability for intervention) Ability to make use of supervision 3 Types of Graduate Programs Presentation of the model we have used to teach psychotherapy with 5 different graduate cohorts one distance online presentation only, one inclass, in a large city University, and one hybrid program, with in person workshop immersion and online group sessions. Competency based teaching materials, and student/ training workshop evaluation tools. ONLINE BRICK & MORTAR HYBRID Teaching Strategy: Basics and Beyond : Primary Text To share a successful strategy for providing PMHNP students clinical training in two modalities of psychotherapy in a format delivered to a totally online cohort, a traditional campus based cohort, and students in a hybrid program with week long on campus immersions. Beck, J. (2011). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press Lusk 6
7 Sessions: Group Delivery Thematic analysis revealed greater understanding of CBT through the simplicity and organization of the COPE sessions. Students also benefited from their peer interaction and felt safe practicing this new skill in a group atmosphere. The Clinical Training : A clinical training experience has been developed and delivered by PMHNP faculty to students in an Online PMHNP program, a traditional on Campus University based PMHNP program, and a hybrid online program with on campus summer immersions. The students received a content based workshop on Cognitive Behavior Therapy (CBT) basics and adaptation of CBT for children and adolescents. The didactic workshop was followed by weekly small group sessions (for 7 weeks) that allowed the students to lead and experience being a member of a therapy group as they learned the process of CBT. We used a CBT 7 session manual for adolescents in the weekly sessions. Student outcomes were measured, and data analyzed for common themes. Students in the group sessions,(face to face and online, reported that they learned how to do CBT, group process, stages of group psychotherapy and also how CBT is developmentally presented to adolescents and children Future directions: This module can be delivered easily in any PMHNP program and will provide the students with clinical training (active skill development with faculty supervision as well as didactic/ knowledge) in Group psychotherapy, Cognitive Behavioral Psychotherapy and evidence based psychotherapy for children and adolescents. The process: Faculty Role Basics of CBT: Supervised Practice Student Feedback Evaluation Tool: anonymous after 7 sessions of COPE practice Beck CTRS Cognitive Therapy Rating Scale References: American Psychiatric Nurses Association. (2014). Psychiatric Mental Health Nursing: Scopes and Standards of Practice (2 nd Ed. Silver Springs, MD; Nursebooks.org. Beck, J. (2011). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press. Lusk, P. & Melnyk, B.M. (2011). The brief cognitive behavioral COPE intervention for depressed adolescents: Outcomes and feasibility of delivery in 30 minute outpatient visits. Journal of the American Psychiatric Nurses Association. 17(3), 226 236. Lusk, P. & Melnyk, B.M.(2011). COPE for the treatment of depressed adolescents: Lessons learned from implementing an evidence based practice change. Journal of the American Psychiatric Nurses Association. 17(4), 297 309. Melnyk, B. (2013). COPE (Creating Opportunities for Personal Empowerment) for Teens: A 7 Session Cognitive Behavioral Skills Building Program (3 rd edition). Columbus: COPE2Thrive Roth, A. & Piling, S. (2008). Using an evidence based methodology to identify the competencies required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioral and Cognitive Psychotherapy. 36, 129 147. Wheeler, K. (Ed.) (2014). Psychotherapy for the advanced practice psychiatric nurse. New York, NY: Springer. Lusk 7