challenges and realities of teaching psychotherapy: a survey of psychiatric-mental health nursing...

72 Perspectives in Psychiatric Care Vol. 44, No. 2, April 2008

Blackwell Publishing IncMalden, USAPPCPerspectives in Psychiatric Care0031-59900031-5990XXX

ORIGINAL ARTICLES

Challenges and Realities of Teaching Psychotherapy: A Survey of Psychiatric-Mental Health Nursing Graduate Programs


Kathleen Wheeler, PhD, APRN-BC, and Kathleen Delaney, DNSc, APRN-BC

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

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.

T

he completion of the Psychiatric-Mental HealthNurse Practitioner (PMHNP) Competencies in 2003reaffirmed the importance of psychotherapy as anessential skill for all advanced practice psychiatricnurses (National Panel for Psychiatric-Mental HealthNP Competencies [National Panel], 2003). With thecompetencies delineated and the endorsement of theseby the Commission on Collegiate Nursing Education(CCNE) for accreditation, it is clear that all graduateadvanced practice psychiatric nurse programs seekingCCNE accreditation must teach these skills. Psychiatric-Mental Health Clinical Nurse Specialist (PMHCNS)programs have taught psychotherapy skills since theinception of this role in 1952 when Peplau developedthe first PMHCNS program at Rutgers University. Herinitial description of the nurse–patient relationshipevolved into the one-to-one relationship, then counseling,and finally psychotherapy (O’Toole & Welt, 1989).Specialists in the field were able to conduct psycho-therapy while generalists counseled and conductednurse–patient relationships.

Numerous challenges have been identified inacquiring the skills and competencies needed forcompetency in this area (Paquette, 2006; Wheeler &Haber, 2004), not the least of which is defining whatpsychotherapy content is essential. A related challengeis how to fit this material into a reasonable number oftheoretical and clinical hours within the alreadyburgeoning amount of curricular content requiredfor the psychiatric-mental health advanced practiceregistered nurse (PMHAPRN) programs. This surveywas undertaken in order to determine what and howpsychotherapy content is taught in advanced practicepsychiatric nursing graduate programs in the UnitedStates. This survey was completed in 2005 after thePMHNP Competencies were endorsed, and it is

Perspectives in Psychiatric Care Vol. 44, No. 2, April 2008 73

important because it reflects a baseline upon which todevelop and track future curricular changes foradvanced practice psychiatric nursing education.

Survey of Graduate Programs

Design and Methods

The survey was mailed to 120 university/college-based psychiatric-mental health nursing programsfrom a list compiled from the American PsychiatricNursing Association (APNA) Web site and APNAEducational Council and a customized list obtainedfrom the American Association of Colleges of Nursing(AACN). A pilot survey that consisted of 20 questionswas sent to 5 participant schools via email. Approxi-mately half the questions were forced-choice optionsand half had room for more narrative responses.Several open-ended questions were also asked. Basedon the responses from the pilot schools, several minorchanges were made to combine several questions andto clarify and simplify content. The second draft wassent to 120 participant schools via email, with an initialresponse from 34 schools. A further question was thenadded regarding whether faculty felt students hadachieved competency in psychotherapy upon graduation.This final draft was sent to those schools that had notyet responded, with 29 more responses obtained.

Findings

Of the 120 schools contacted, a total of 68 programsresponded, for a response rate of 57%. To begin, facultywere asked to report the types of psychiatric-mentalhealth advanced practice nursing graduate programsthey offered; many indicated that they offered severalprograms. The majority of programs (84%) offered thePMHNP adult program, with the PMHCNS programa close second at 62%; 53% offered a PMHNP familyprogram while 42% offered a child/adolescent PMHCNSprogram; 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 nursepractitioner or family nurse practitioner curricula. Wefurther asked what certification exams their graduateswere qualified to take upon graduation (see Figure 1).

There was a wide range for the number of credithours required for completion of the program (from24 to 77 credits), with the majority (more than 60%)reporting that 45–55 credits were required. The highestnumber of credits required was for the PMHNP adultprograms, ranging from 40 to 72, and the PMHCNSranged from 40 to 54 required credits. Postmaster’sprograms were 16–32 credits. It should be noted that itwas not clear in some cases how the total credits werecalculated and what the hour-to-credit ratio was.

One survey question asked how faculty integratedchild/adolescent or geriatric content into their pro-gram of study, and a follow-up question asked whatadditional courses were required for their PMHNPfamily program. Thirty-three programs reported thatthe PMHNP family programs added additionalcoursework, as illustrated in Figure 2, with 12 of thesespecifying the courses added. Open-ended comments

Figure 1. ANCC Certification Exams Graduates Sit For

Notes: ANCC = American Nurses Credentialing Center; PMHNP= Psychiatric-Mental Health Nurse Practitioner; PMHCNS =Psychiatric-Mental Health Clinical Nurse Specialist; F/ANP =Family/Adult Nurse Practitioner.

74Perspectives in Psychiatric Care Vol. 44, No. 2, April 2008


to this query demonstrated a diversity of approachescurrently in use to create PMHNP family curriculum.For example, respondents reported for PMHNP familyprograms that content is integrated across the lifespanand that there is no curriculum difference in the adultor family PMHNP, but more child/adolescent clients areincluded for the family students in the clinical practica.In addition, respondents indicated that there exists amultitude of combinations for integrating populationsduring clinical, with some programs integrating adultand geriatric content while others explained that theavailability of practica sites most often determined thepopulation that students worked with.

Questions relating to how the principles of thetherapeutic relationship (therapeutic alliance, empathy,positive regard) are taught revealed that only 2% hada separate course for this content; 70% included this inthe individual therapy course; and 62% integratedthis content throughout the curricula. Ninety percenttaught several models of psychotherapy, while only4% taught one model only (see Figure 3). In additionto those not commonly cited in Figure 3, other typesincluded self, narrative, gestalt, reality therapy, rationalemotive, brief therapy/solution focused, existential,feminist, crisis intervention, motivational interviewing,dialectical behavioral, exposure response prevention,desensitization, supportive, social skills training, stressmanagement, assertive training, conflict resolution,reminiscence/life review, stages of change, Adleriantherapy, eye movement desensitization and reprocess-ing (EMDR), family therapy, transpersonal/personcentered, and Yalom group therapy.

The diversity of approaches to teaching psycho-therapy was also reflected in the number and type oftextbooks cited as used in the programs. More than 80different texts were reported as used. The top eightcited as most popular were non-nursing texts (seeTable 1). The two nursing textbooks most often usedwere

Advanced Practice Psychiatric Nursing

by Shea,Pelletier, Poster, Stuart, and Verhey (1999, now out ofprint) and

Principles and Practice of Psychiatric Nursing

by Stuart and Laraia (2005).With respect to practica sites, preceptors, and

practica hours, faculty responses revealed that adiversity of practica sites were used, with manyprograms tailoring the site to meet the student’s needsor interests as well as geographic exigencies. Onerespondent said that prescribers were needed, notpsychotherapists, and it was difficult to find appropriatepsychotherapy sites. In addition to the sites listedin Figure 4, nursing homes, day treatment centers,specialized settings for older adults, prisons, psychia-trists, and other private practice offices were alsoreported. Credentials of preceptors also varied widely(see Figure 5), with those in the “other” categoryincluding 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

Figure 2. How Do You Adjust Your Program for the PMHNP-NP Family? (n = 13)

Figure 3. Models of Psychotherapy Taught


respondents noted that for psychotropic medications,psychiatrists or advanced practice registered nurses(APRNs) were utilized, while for psychotherapy,licensed clinical social workers or PMHCNSs wereused. Rural areas cited mostly licensed clinical socialworkers or psychiatrists as preceptors.

Several questions were asked relating to whether therewas a specified number of practice hours designatedfor psychotherapy and what treatment modalities weretaught. Fifty percent of the queried programs did

dedicate hours toward psychotherapy, while 50%combined both psychotherapy and medical/psychiatricmanagement in practica hours. A range of 500–900clinical hours were required for the schools’ totalprograms. A wide range was reported for each modalityfor those schools that did designate a specifiednumber of practica hours: 50–440 for individualpsychotherapy, 30–250 for group therapy, and 10–180for family therapy (see Figures 6–8). Furthermore,some programs reported that: “The student chooses

Table 1. Top Eight Most Popular Texts

1. Corey, G. (2005). Theory and practice of counseling & psychotherapy (7th ed.). New York: Brooks/Cole. (n = 9)2. Kaplan, H. I., Sadock, B. J., & Grebb, J. A. (1994). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (7th ed.).

Baltimore, MD: Williams & Wilkins. (n = 7)3. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press. (n = 6)4. Dewan, M. J., Steenbarger, B. N., & Greenberg, R. P. (Eds.). (2004). The art & science of brief psychotherapy: A practitioner’s guide.

In G. O. Gabbard (Series Ed.) Core competencies in psychotherapy. Washington, DC: American Psychiatric Association. (n = 4)5. Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: WB Saunders. (n = 4)6. Corsini, R. J., & Wedding, D. (Eds.). (2005). Current psychotherapies (7th ed.). Itasca, IL: Peacock. (n = 3)7. Morrison, J. R. (1995). The first interview: Revised for DSM-IV. New York: The Guilford Press. (n = 3)8. Yalom, I. (1995). The theory and practice of group psychotherapy (4th ed.). New York: Basic Books. (n = 3)

Figure 4. Types of Practica Sites

Notes: Outpt. = outpatient; Inpt. = inpatient; ER = emergency room.

Figure 5. Average Percentage Use of Various Preceptors

Notes: PMHCNS = Psychiatric-Mental Health Clinical NurseSpecialist; PMHNP = Psychiatric-Mental Health Nurse Practitioner;APRN/ARNP = Advanced Practice Registered Nurse/AdvancedRegistered Nurse Practitioner.



2 out of 3 treatment modalities,” “Family was requiredfor PMHCNS only,” “Individual and group were com-bined,” “Varies according to practice site,” and “Onlygroup hours mandated.”

Virtually no programs required that students be intheir own psychotherapy, and several explained thatthis was because of university restrictions. Facultydid note, however, that psychotherapy is stronglyencouraged: “Students are expected to practicemindfulness-based therapies,” and “Group therapywas encouraged.” A last, most revealing questionwas “Upon graduation, do you believe that yourstudents have achieved competency as a novice

psychotherapist?” Only 2 respondents said “no,”15 said “yes,” and the others offered qualified commentssuch as: “Very novice,” “For the most part, competencyis a stretch,” “Know they have to pursue more trainingafter they finish the program,” “About 60% do,” “Verybeginning competency,” “Yes, for individual, not forfamily or group,” “Clinical experiences limited in ourarea,” “Most of the time,” “We encourage furthertraining,” “Encourage continued supervision andtherapy,” and “Don’t envision a future role as apsychotherapist.”

Discussion

In summary, the results of this survey revealed adiversity of innovative, creative programs with aplurality of treatment approaches taught. The PMHadult programs were most popular, with many programsoffering both PMHNP and PMHCNS programs.Only one school offered only the PMHCNS programwithout the PMHNP, and this may indicate that “freestanding” PMHCNS programs may be dying out orthat perhaps this is an artifact of those who choseto respond to this survey. Indicators from AACNenrollment data and the American Nurses Credential-ing Center data would support the move toward NPeducation (Duffy et al., 2004). This is particularlynoteworthy as the PMHCNS is cited most often as apreceptor. Thus, as the specialty is in transition, there

Figure 6. Individual Psychotherapy Practica Hours (n = 31)

Figure 7. Group Psychotherapy Practica Hours (n = 28)

Figure 8. Family Therapy Practica Hours (n = 17)


is often placement with one discipline while super-vision is conducted by another.

Implications for Education

There are many challenges today in graduatepsychiatric nursing programs that mitigate againstPMHAPRNs attaining competency in psychotherapy.One challenge for nursing education is how, withoutincreasing the credit load, faculty might design pro-grams that teach requisite psychotherapy skills as wellas the essentials that are required of graduate nursingcurricula. The reality of competing demands requiresprograms to devise coursework that can be completedin a reasonable amount of time and with a credit loadthat allows the program to remain competitive. Inaddition, students need to be educated in multiplesciences (i.e., psychopathology, neurobiology, psycho-pharmacology, and psychotherapy interventionsfor individuals, couples, and groups). This makes itimpossible in a short amount of time, usually 2 yearsfor most graduate nursing programs, to attain

proficiency

in psychotherapy. However, competency must beachieved to meet the core competencies of the PMHNPCompetencies (National Panel, 2003).

Clinical Sites

Another current challenge for graduate nursingeducation is the difficulty of finding clinical sites forpsychiatric graduate nursing students to practicepsychotherapy. Students are frequently thwarted inlearning even the basics of treatment when the onlyclinical sites available are those with PMHAPRNsmanaging medication. With economics driving jobdescriptions, many settings have social workersconducting psychotherapy while the PMHAPRN mostoften serves as prescriber. This is cost-effective forthe agency or clinic because PMHAPRNs usually earnmore per hour than social workers, but it restricts theopportunities for the student nurse-psychotherapistto practice psychotherapy. PMHAPRN students can

sometimes work out an arrangement where they cansee their preceptor’s patients for psychotherapywhile the psychiatric PMHAPRN preceptor managesthe medication. However, this is only feasible ifthe preceptor is competent in psychotherapy andcan adequately supervise the student. In addition tothe liability issues with this arrangement, spaceconstraints, agency policy, or lack of adequatepsychotherapy supervision may prohibit the studentfrom seeing an adequate caseload of patients forpsychotherapy. Consequently, most graduate psychiatricnurses are likely to leave their master’s programs witha less than adequate knowledge base in this area andmay not feel competent to practice psychotherapy. Inthis era of decreasing clinical therapy sites for studentsand competing demands on their time, continuedcollaboration and innovation are needed.

Core Curriculum Standardized Guidelines

Although the PMHNP Competencies state that thePMHNP “conducts individual, group and/or familypsychotherapy” (National Panel, 2003, p. 7), this is ageneral statement, and standardized guidelines for anPMHAPRN core curriculum incorporating psycho-therapy skills have, as yet, not been developed. PMH-APRNs need to further delineate specific indicators formeeting specific psychotherapy competencies. Forexample, competencies might include: The student isable to establish a therapeutic alliance, or can formulatea psychodynamic explanation, or maintain a treatmentframe and boundaries. Then, behaviors and indicatorsthat illustrate the achievement of these competenciesneed to be identified. In addition, many questions areraised regarding how to incorporate these skills, notthe least of which is what models or approachesreflect essential content needed for a beginningpsychotherapist. Should only one or two models ofpsychotherapy be taught for depth instead of breadth?Standardized guidelines delineating essential contentthat meet specific competencies would bring somepedagogic consistency.



Consistency in Programs

The problem of achieving consistency in requiredpsychotherapy competencies multiplies in the PMHNPfamily programs. Based on the survey, there is consider-able confusion around what the PMHNP familycurriculum should emphasize. Some educators see thisas a lifespan curriculum, while others a family-centeredprogram. How the student will learn psychotherapytechniques suitable to specialty populations is not allclear when the boundaries of the population served andthe clarity of the role remain nebulous. The number ofthe PMHNP family programs has doubled in the last5 years, and currently, approximately 500 PMHNPs holdthis particular certification (Delaney, 2007). Thus, theseprograms have obvious utility, and it would seem thatproviding guidelines for essential content and curriculumwould increase the appeal as well as ensure quality.

Number of Practice Hours

Confusion also exists regarding educational require-ments for the PMHNP postmaster’s certification. Someprograms require 500+ additional practice hours forthe 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 whenan analysis of recent role delineation studies comparingPMHCNS and PMHNP roles found enough com-monalities in these roles that a recommendation wasmade to develop a single psychiatric PMHAPRNexam that would suffice for all APRNs rather than thetwo separate exams that are currently offered (APNA,2006). While this move will undoubtedly resolve adecade-long conflict in the specialty, the finding ofcommonalities in roles does not address the issue ofachieving competency in psychotherapy.

Doctorate of Nursing Practice

Another recent change in nursing education thatwill significantly affect all APRNs is the endorsement

of the doctorate of nursing practice by leaders innursing, the National Organization of Nurse PractitionerFaculty, and the AACN. This new degree is envisionedas a terminal practice degree, is proposed to supplantthe master of science in nursing degree for nursepractitioners by 2015, and will include a clinicalresearch focus. Impetus for this shift came from thelack of parity with other healthcare disciplines, thehigh amount of credits required in current master’sprograms’ curricula, the current and projectedshortage of faculty, and the increasing complexity ofthe healthcare system (Dracup, Cronenwett, Meleis, &Benner, 2005).

Debate continues about whether this terminalpractice doctorate will enhance or dilute advancedpractice. Presently, there are more than 200 programsthat are planning doctorate of nursing practice pro-grams, and some have come to fruition; yet there is nostandardized curriculum. It is not clear how curriculaand program requirements will continue to evolve inorder to provide the needed practice expertise forAPRN students. In addition, faculty need currentexpertise in psychiatric advanced practice in order toeffectively teach, and concerns have been expressedabout whether graduate faculty have greater academicexperience than practice experience because academiatraditionally rewards faculty who publish and doresearch. Clinical practice and teaching are oftenoverlooked in promotion decisions so faculty tend toemphasize research over practice, which may not bodewell for PMHAPRN faculty expertise in psycho-therapy skills.

Implications for Research

Scholarly debate and the development of an overallframework for psychotherapy practice in nursingare needed. A recent textbook by one of the authors(Wheeler, 2008) does provide a framework that anchorspsychotherapy approaches in a holistic nursingparadigm. Whether this model for treatment willbe adopted and widely used by advanced practice


psychiatric nurses remains to be seen. Since 1954 whenPMHCNSs started practicing psychotherapy, Peplau’s(1952) seminal book

Interpersonal Relations in Nursing:A Conceptual Frame of Reference for PsychodynamicNursing

has remained the dominant paradigm forpsychiatric nursing. Since then, the evolution of therole to integrate physical assessment and managingmedical problems in psychiatric patients has createdboundary and ethical issues that are only beginning tobe discussed in the literature (McCabe & Burnett, 2006).

The literature on how psychotherapy is taught issparse to nonexistent for graduate psychiatric nursingeducation, and there is a reliance on other mentalhealth disciplines for textbooks. Recent articles in thisjournal have begun to dialogue on how programs areincorporating the traditional nurse–patient relationshipfocus with specific techniques for psychotherapeuticinterventions (Perraud et al., 2006). More dialoguethrough journal articles and conferences about how toteach psychotherapy is needed. Increased authorshipof textbooks written by nurse psychotherapists is alsoneeded.

As the PMHAPRN role is further defined andpsychiatric nursing scholarship continues to evolve,research will be needed in order to determine whatmodels of curriculum are best for teaching psycho-therapy. Outcome studies then should follow on theeffectiveness of nurses as psychotherapists, withevidence-based protocols and policies developingfrom these findings. These data then can be used toshape curricular changes.

Implications for Practice

Psychotherapy practice constraints exist that aresystem issues relating to reimbursement, with manysettings marginalizing advanced practice nurses asmedication managers who wish to practice psycho-therapy. Managed care allows only 15 min for suchappointments, which does not allow time to develop ameaningful psychotherapeutic relationship. APRNsmay be able to negotiate with the variety of settings

employing them to include psychotherapy withmedication management as part of their job descrip-tions. Further clarification of the PMHAPRN role andscope of practice to consumers, employers, andmanaged care is essential. It is incumbent upon PMH-APRNs to seek ongoing postmaster’s supervisionand further certification in psychotherapy throughadditional education to ensure expertise and proficiencyafter graduation. Perhaps there should be a requiredinternship prior to psychotherapy practice. Furtherresearch might include a survey of those nurse psycho-therapists in practice in order to share and disseminatesome of the creative solutions colleagues have devisedwho practice in a variety of settings.

Conclusion

The challenges for the profession are many, not theleast of which are the dominant reductionistic biologicalparadigm, consumer demand for a quick fix, and theinfluence of powerful pharmaceutical money forresearch and marketing. Although psychotropicmedications have changed the lives of many withserious mental illness, the integration of relationshipand psychotherapy skills with psychopharmacotherapyis essential in order to maximize the benefit ofmedications (Johnston, 2008). Prescribing in a vacuumwithout the attending relationship skills in the contextof a psychotherapeutic relationship marginalizes thenurse as well as the patient.

“The centrality of relationship to healing and thesubjective intuitive stance necessary in knowing anotherperson is rooted in qualitative data and is dissonantwith the outcome driven, quantitative philosophy ofmanaged care and contemporary biomedical psychiatry”(Wheeler, 2008, p. viii). However, perhaps as wecontinue to reaffirm the primacy of relationship to ourspecialty, psychotherapy may move to center stageand the nurse–patient relationship will reassume therelevance and importance of our historical roots.The results of this survey provide a clear mandate forpsychiatric nursing graduate education. Clarity of



content, curriculum guidelines, and further develop-ment of competencies for psychotherapeutic skills areneeded. The educational and practice challengesinherent in attaining competency in psychotherapypresents opportunities for our collective professionalgrowth as we continue to collaborate, evolve, unify,and strengthen our specialty.

Acknowledgment.

The authors wish to thank therespondents from the 68 schools of nursing who par-ticipated in this survey.

Author contact: [email protected], with a copy tothe Editor: [email protected]

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