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New Research: PMH-NP Programs & Psychotherapeutic Skills

New Research: PMH-NP Programs & Psychotherapeutic Skills
Daniel Wesemann, Sean Convoy, Dawn Goldstein, Kate Melino

Psychotherapy is a core part of the PMH-APRN role – but how are current graduate programs ensuring that students acquire skills in this area? A research article published OnlineFirst in the Journal of the American Psychiatric Nurses Association summarizes the results of a national survey on this topic. Authored by APNA members Daniel Wesemann, Sean Convoy, Dawn Goldstein, and Kate Melino, this paper provides insights into how PMH-NP programs ensure students’ competency in acquiring the skill of psychotherapy. Below, the authors discuss their research and more!

Your research investigates how PMH-NP programs are delivering education on a key part of the PMH-APRN role in today’s environment – it’s a complex area! How did you home in on your four objectives that guided this study?

Thanks for recognizing that this is a complex area. We wanted to start our work with the assumption that all PMH-NP programs are doing their best in teaching psychotherapeutic content to their students. Yet with broad standards provided by the 2013 NONPF PMHNP competencies and the ANCC requirement of covering at least two psychotherapeutic content areas, we wanted to see how much variance there is in PMH-NP programs teaching psychotherapeutic content.

We really wanted to know what psychotherapy theories are being covered and how programs were evaluating this learning of their PMH-NP students. We wanted to know how much time PMH-NP programs invest in students through didactic and practicum education to the development of psychotherapeutic skills.

We also knew from our own PMH-NP programs that securing preceptors for teaching PMH-NP students to use psychotherapeutic skill in clinics is becoming increasingly difficult. We wanted to see if PMH-NP programs were using more allied providers (i.e. psychologists or social workers) to precept for psychotherapeutic skills and thereby using fewer nurses (i.e. PMH-NPs & PMH-CNSs).

Lastly, we really wanted to know what interest the PMH-NP students had in learning this content. We did not know if it was reasonable or not to ask program directors to tell us about student perspectives but we wanted to know if PMH-NP students are choosing to attend programs based on the extent of the program’s psychotherapeutic content. We also wanted to know if PMH-NP students were resistant to learning or applying psychotherapeutic content within their plans of study and possibly choosing to leave based on their program’s level of psychotherapeutic content. There were many other areas of interest to explore but we did not want to develop a survey that would take hours to fill out!

How do you hope APNA members use the information shared in your publication?

We hope that APNA members can use the findings to support and stimulate conversation between PMH-NP faculty teams on their commitment to including psychotherapy in PMH-NP education, and how that vision is currently being realized – or what could be done to do so. The article includes several reflection questions to guide a discussion on clinical opportunities, curricular scaffolding, evaluation, and community advocacy.

What discoveries or themes that emerged from this study surprised you?

We used Brawn and Clarke’s Reflexive Thematic Analysis to analyze the qualitative data collected in this survey because of its accessible and theoretically flexible approach to qualitative data. Reflexive thematic analysis does not pretend to be unbiased. Given the nature of the data collected and the relationship the team had with it, this approach seemed both logical and efficient.

As I suspect many of your readers already anticipate, the findings from our first survey question (What would your PMHNP program require to improve psychotherapeutic competence delivery?) yielded a usual suspects list of recommendations. Participants identified pre-matriculation training and certification opportunities to develop psychotherapy skills like the ANCC Psychiatric-Mental Health Nursing certification and the APNA Transitions in Practice program. Survey participants noted post-graduation training and certification opportunities to develop psychotherapy skills like the Beck Institute and the Centers for Deployment Psychology program. Other recommendations, like increasing program academic credit hours for a stand-alone psychotherapy course, introducing/increasing low and high-fidelity simulation hours specifically focused on psychotherapy, pursuing inter-professional academic partnerships with clinical psychology, and social work programs were also recommended.

Our second survey question (What outcome measures used to evaluate psychotherapy skills competency?) explored the varied strategies used to evaluate psychotherapy education, including low fidelity simulation with faculty, high fidelity simulation with simulation experts and standardized patients, simulation experiences that were both formative and summative in design, evidence based competency checklists, private company predictor examinations, preceptor evaluation, and individualized cognate work specifically in psychotherapy.

Considering our results in relation to the established evidence there are some linkages. Of the limited evidence that is out there related to the development of psychotherapy skills in an advanced practice psychiatric-mental health nursing program, most of the evidence focuses on medical students, medical interns, and psychiatry residency training programs and not advanced practice nursing. The evidence that does exist concentrates more on the “what” than the “how” of psychotherapeutic educational delivery. This suggests there is a clear and present hole in the body of knowledge that needs to be filled. Linking this back to a central premise at the beginning, none of us should be surprised that there is limited evidence in an area that has been largely uncultivated in our profession for years.

Are there any examples of programs providing psychotherapy education in an innovative way that you would like to highlight for readers?

Sean Convoy: Duke’s PMHNP program is one of the newer PMHNP programs in the country. I want to take a moment to publicly thank Dr. Kathleen Delaney for her initial consultation with Duke during our program development period in 2017 and Dr. Pamela Wall for her early leadership during the program’s inception in 2017 & 2018. At Duke, students can achieve the PMH-NP certification through 2 paths – a traditional MSN program (8 semesters) or a postgraduate certificate program (~ 4 semesters). Regardless of path, the last 4 semesters find both MSN and post-graduate certificate students cohort up together. Our 1st semester finds students embroiled in a foundations course that focuses on the basic PMH-NP toolkit which lays psychotherapeutic groundwork for students as they learn about concepts like bias, transference & countertransference, transactional analysis, Socratic questioning, guided discovery, Rogerian unconditional positive regard, and observing ego. During this first semester in PMH-related coursework, students are not yet in practicum. Rather, we use a combination of both low and high-fidelity recorded simulation to galvanize these formative skills. During the next semester, we use Beck’s Cognitive Therapy: Basics and Beyond as a textbook and deliver didactic training in CBT intermixed with low fidelity simulation in the form of role-play between faculty and student. After didactic exposure, we schedule 1:1 Zoom sessions with students throughout the remainder of the semester to reinforce the content with additional role-play opportunities. The next semester finds students exposed to CBT for Insomnia training delivered in a similar fashion to the previous semester’s CBT training with both didactic training and subsequent faculty role-playing opportunities. In the final semester, students can take an elective 1 credit course, Advanced Cognitive Behavioral Therapy, where they are expected to add critical depth to their psychotherapy skills by focusing on a specific population of interests that they expect to serve after graduation. In the past, students have focused on varied off shoots of CBT like trauma-informed CBT, mindfulness-based CBT, CBT for substance use disorders, and CBT for chronic pain. In this elective course, students are required to participate in 3 additional simulation sessions with faculty and develop a scholarly project reflective of their specialty interest. As designed, Duke’s approach to psychotherapy meets the ANCC standard, but also allows each student to leave the program with some psychotherapeutic phenotypic variation that we hope enriches our national PMH-NP gene pool.

Daniel Wesemann: We have heard from several other PMH-NP programs across the US since we have presented this content at multiple national conferences. We have heard several programs are using the Beck’s Institute for Cognitive Behavioral Therapy as foundational to their psychotherapeutic content within their PMH-NP program. This has several advantages, as the Beck’s Institute has an evidenced based and structured approach to delivering this content. The problem is that while some programs get discounted group rates, this cost is typically covered by the PMH-NP students and can be a significant cost on top of tuition and room and board. Dr. Kathleen Wheeler at Fairfield University has also become an EMDR (Eye Movement Desensitization Reprocessing) trainer and has worked through the EMDR International Association to provide EMDR certification for PMH-NP student both at her university as well as completed virtually for PMH-NP students across the US.

Kate Melino: In January 2021, three University of California Schools of Nursing (UCSF, UCLA, and UC Davis) introduced a new multi-campus post-Master’s PMH-NP certificate program with a 3-quarter, integrated psychotherapy curriculum across the lifespan, emphasizing attachment theory, CBT, and MI. In addition to practicing psychotherapeutic skills in clinical practicum, students participate in both synchronous and asynchronous didactic psychotherapy content, with 3 yearly immersion workshop weekends during which students engage in high-fidelity simulation in individual and group modalities.

Anything else you’d like to share?

We hope this information continues to highlight the important role of the PMH-NP within the healthcare system. While many PMH-NPs are excellent prescribers of psychopharmacological agents, we hope the role never loses the respect and training for the psychotherapeutic communication and psychotherapy skills needed to help those with mental illnesses.

We are also planning to send out this survey again in 5 years (2025) to all the PMH-NP program directors/coordinators in the United States, so keep an eye on your inbox for the survey invitation coming out soon. We cannot wait to compare the data between intervals and report these findings again!