In the United States, the high prevalence of chronic illnesses among adults (Anderson, 2010) has created a primary care system with a focus on chronic disease management. With easily accessible clinical practice guidelines, primary care providers effectively manage problems associated with chronic illnesses, especially around physical symptomatology. However, one area of concern is the inadequate attention given to the mental health of adults who experience chronic illnesses (World Health Organization & Calouste Gulbenkian Foundation, 2014). Adults with diabetes, hypertension, or heart disease have high incidences of functional impairment and increased symptom burden that may threaten their mental well-being (Robert Wood Johnson Foundation, 2011). Physical health and mental health intermingle and are interdependent, with one often leading to or exacerbating the other (Campayo et al., 2010; Rotella & Mannucci, 2013). Therefore, both areas deserve attention in primary care. Simply put, achieving physical health is impossible without addressing mental health (Ivbijaro & Funk, 2008).
Approximately 70% of primary care visits are triggered by psychosocial complaints (Robinson & Reiter, 2007). Within the context of chronic disease, patient complaints pertain to issues associated with self-management, treatment adherence, burden of symptoms, and psychosocial integrity. Evidence shows that when mental health is threatened, the management, progression, and outcomes of chronic illnesses and health conditions worsen (Grenard et al., 2011). Thus, leading organizations, such as the World Health Organization (2008) and the Health Resources and Services Administration (U.S. Department of Health and Human Services, 2010), have strongly endorsed the integration of mental health in primary care. Yet, such an approach assumes two premises: an adequate workforce, with expertise in mental health, and a sustainable model for integration. Both are still lacking in the United States (Olfson, Blanco, Wang, Laje, & Correll, 2014). An alternative strategy is to prepare primary care providers with competence in addressing the mental health needs of the chronically ill (U.S. Department of Health and Human Services, 2010). To this end, this article describes the beginning efforts at Duke University School of Nursing to more fully integrate mental health concepts in its adult–gerontological nurse practitioner and family nurse practitioner (AGNP and FNP, respectively) curricula.
Mental Health Interprofessional Training Grant
In 2013, the Duke University School of Nursing received a training grant in advanced nursing education, and the primary goal was to enhance its AGNP and FNP curricula by integrating relevant mental health concepts in courses that address chronic disease management. As a result of this grant, Duke University School of Nursing faculty (C.C.H., K.P., M.B., S.E.) partnered with selected faculty from the physician assistant (PA [M.E.B.]) and medical (MD [K.F.]) programs within the Community and Family Medicine Department at Duke University School of Medicine and mental health clinicians (a clinical psychologist [L.B.] and a psychiatric nurse practitioner [J.B.]) to form the Mental Health Interprofessional (M-HIP) team. The inter-programmatic partnership was intentional so that the M-HIP project could impact as many primary care learners as possible. Collectively, the M-HIP team possesses the academic and clinical expertise necessary for successful project development and implementation. The M-HIP team also involved leadership within the Duke University School of Nursing and the PA and MD programs in planning and developing the project’s blueprint for mental health integration. The leadership buy-in was crucial for project sustainment due to the fact that funding was for 3 years only.
The M-HIP team faculty embarked on several important and preparatory steps prior to the development of modules for curricular enhancement. First, the M-HIP team faculty identified primary care competencies related to mental health that were inadequately addressed in the existing nurse practitioner curricula. Second, the M-HIP team faculty selected mental health concepts that would provide the context for curricular enhancement. Finally, the M-HIP team faculty identified courses in the curricula that would be amenable to mental health integration. This series of steps was important, as the competencies and concepts provided the focus and context for the M-HIP team’s pedagogical efforts. In addition, the early identification of courses for enhancement has allowed the M-HIP team to approach course faculty, whose buy-in was critical for this project. Each step is described below.
Curricular Review to Identify Areas for Enhancement
The M-HIP team believes that competency development should drive efforts in curricular enhancements. Thus, to determine areas for enhancement, the M-HIP team faculty reviewed the AGNP and FNP primary care competencies endorsed by the American Association of Colleges of Nursing (2010). Next, from these competencies, the M-HIP team identified those competencies that are related to mental health within the context of chronic disease management. Those mental health–related competencies were then reviewed by Duke University faculty who teach core nurse practitioner courses, such as Advanced Pharmacology, Physical Assessment and Diagnostic Reasoning, and Clinical Management to identify those competencies that needed strengthening in their respective courses. Specifically, reflecting on their respective courses, the faculty evaluated each competency as being discussed adequately, discussed inadequately, or not applicable to the course.
The results of the competency course content mapping activity revealed that of the nine practice domains in the AGNP and FNP competencies, opportunities for curricular enhancement existed in seven domains, such as Assessment, Diagnosis, Planning, Nurse Practitioner–Patient Relationship, Professional Role, Managing and Navigating the Health Care System, and Spiritual Competence. As an example, under the domain of Assessment, the following competencies were inadequately covered in the AGNP and FNP core nurse practitioner courses:
- Screens for acute and chronic mental health problems and disorders.
- Obtains health information from collateral sources as needed.
- Assesses individuals with complex health issues and comorbidities, including the interaction with acute and chronic physical and mental health problems.
- Assesses the individual’s and family’s ability to cope with and manage developmental (life stage) transitions.
- Assesses the effects of illness, disability, and injury on the individual’s functional status, independence, physical and mental status, social roles and relationships, sexual function and well-being, and economic or financial status.
- Assesses for syndromes and constellations of symptoms that may be manifestations of other common health problems (e.g., risk-taking behaviors, self-injury, stress, incontinence, falls, delirium, depression).
- Determines the need for transition to a different level or type of care based on an assessment of an individual’s acuity, stability, resources, and need for assistance.
The M-HIP PA and MD program faculty also reviewed the list of competencies identified by Duke University faculty as areas for strengthening and found that their respective primary care curriculum has similar areas of need. The establishment of a consensus on areas for enhancement provided a clear direction on the focus of learning activities. The next task was to identify mental health concepts that are relevant in chronic disease management so that these concepts can be used as the backdrop to address the competencies in need of strengthening.
Selection of Mental Health Concepts for Module Development
Early in the project, the M-HIP team faculty unanimously agreed that the focus of the work should be on mental health concepts and not on mental disorders (i.e., depression, anxiety, schizophrenia). Per grant deliverables, the M-HIP team was committed to identifying five mental health concepts. Each concept would drive the development of a learning module. A module consists of different learning activities, all geared toward enhancing the learners’ understanding about the concept.
Led by the mental health clinicians in the team, the M-HIP team faculty initially identified the following 12 mental health concepts with high relevance in chronic disease management among adults:
- Therapeutic communication.
- Recovery model.
- Posttraumatic stress.
- Spectrum of emotions.
- Validation skills.
To allow for vetting, the 12 concepts and their definitions were sent to the Duke University School of Nursing, PA, and MD programs faculty. The faculty were asked to rank the concepts based on their significance in the primary care of adults with chronic illnesses. The M-HIP team reviewed the rankings and discussed each concept in detail again but, this time, with the benefit of additional opinions from a broader faculty base. In the discussions, the M-HIP team faculty deliberated on whether some concepts were extensions of others and whether the concepts had dual applicability—meaning that they are relevant to both patients and providers.
After many discussions and deliberations, the M-HIP team identified five mental health concepts for module development: (a) spectrum of emotions, (b) validation skills, (c) self-management, (d) resilience, and (e) diversity. Each is described below.
Spectrum of Emotions. Emotions are fundamental and primary reactions to internal and external stimuli. In chronic disease management, providers need to recognize patients’ emotions that may direct responses to the challenges brought about by the symptomatology of the disease and by the alteration in lifestyle that is needed to manage the disease. Of importance, providers need to be aware of their own feelings toward patients’ emotions. From this foundation, providers can develop insight into how emotions affect interprofessional interactions and to learn better ways of assisting patients in self-management and promoting resilience and recovery (Thomas & Cohn, 2006).
Validation Skills. Validation involves seeing the truth in what the patient is saying and letting the patient know that his or her experiences and reactions make sense. Validation does not mean approval; it means understanding from the patient’s perspective that his or her behavior makes sense (Linehan, 1997). Together with the spectrum of emotions, validation skills provide a strong foundation for therapeutic communication.
Self-Management. Self-management means taking responsibility for one’s own well-being. Within the context of chronic illnesses, self-management is closely linked to treatment adherence. Adherence has a spectrum of core components, which include identifying goals, monitoring progress, and coordinating care. To improve self-management and patient outcomes, primary care providers should be cognizant of the role they can play to promote adherence. Specifically, two skills have been shown to improve adherence among chronically ill adults—prioritization and decision making (Lee et al., 2015; Schulman-Green et al., 2012).
Resilience. Resilience is the ability of a person to withstand the many challenges presented by chronic illnesses (Wagnild & Collins, 2009). Primary care providers can promote resilience by helping a patient to see his or her strengths and potential possibilities to make behavioral changes toward a new normal (Edward, 2013; Leppin et al., 2014).
Diversity. Because each individual carries a unique perspective, diversity is an important concept in the management of chronic disease. In 2004, the Institute of Medicine reported the widespread existence of health disparities due to a lack of cultural sensitivity among primary care providers. In addition to individual idiosyncratic preferences brought about by the interplaying of many factors, such as race, gender, and educational status, primary care providers must acknowledge the influence of family and kinship over health attitudes and beliefs (Davidson et al., 2007).
Plan for Curricular Enhancement
After the identification of the five mental health concepts for module development, the M-HIP team faculty reviewed their respective curricula to identify the courses that are most amenable to housing the modules. The most important factors considered were the fit of the mental health concepts with the course’s objectives, as well as the receptivity of course faculty to incorporating mental health modules. For the Duke University School of Nursing’s AGNP and FNP programs, the M-HIP team faculty identified the Physical Assessment and Diagnostic Reasoning course as the best fit for the concept of spectrum of emotions. Because nurse practitioner students are taught how to obtain a pertinent history of present illness in their courses, it is important to teach them about how their emotions may play a role in their provider–patient communication and relationship. For the remaining four mental health concepts, the M-HIP team determined that courses with clinical rotations are ideal, as these will provide students with opportunities for practical applications of the mental health concepts. Therefore, the module for validation skills will be offered in the first clinical course, and the self-care management module will be taught in the second clinical course. The final clinical course will house the modules for the last two mental health concepts. Faculty in the Physical Assessment and Diagnostic Reasoning and clinical courses enthusiastically agreed to incorporate these modules. However, ongoing discussions remain around who will ultimately be responsible for teaching and maintaining these modules.
Challenges and Lessons Learned
Although this article presents only the beginning efforts for curricular enhancement, the M-HIP team encountered several challenges. The original intent of the M-HIP team was to integrate mental health modules into courses offered in the same semester by the Duke University School of Nursing and the PA and MD programs. In this way, active interprofessional learning can be made possible. However, the logistical challenges of bringing interdisciplinary students together at the same time and in one location are insurmountable, as all three schools have different academic calendars. In addition, the three curricula are vastly different in their timing and sequencing of clinical courses. The use of an online platform in offering these modules is currently being considered as an alternative avenue for making interprofessional learning possible, albeit asynchronously. In addition, the modules can be offered in venues outside of academic courses, such as interdisciplinary workshops and seminars. Finally, the modules will be evaluated for use in the training of an interdisciplinary workforce in geriatrics, which is a newly funded program that is spearheaded by faculty at the Duke University School of Nursing.
The M-HIP team benefited by having a 2-day meeting with an external education consultant whose expertise is not only in online teaching but also in interprofessional pedagogy. The consultant provided constructive feedback on the need for the brevity of materials. She also discussed various ways to promote the sustainment of the M-HIP program, which led the M-HIP team to reevaluate activities that were already underway. In hindsight, the M-HIP team would have been better served had they met with the consultant in year 1, rather than in year 2.
Two of the M-HIP team faculty are directors of the AGNP and FNP programs, respectively, at the Duke University School of Nursing. Their insight into the details of these programs allowed the M-HIP team to efficiently identify courses for enhancement. Also, they facilitated communication between the M-HIP team and the school of nursing faculty who promoted faculty buy-in. The M-HIP team does not have the same representation for the PA and MD programs.
Knowing the importance of faculty buy-in, the M-HIP faculty allocated time and effort for the vetting process of the mental health concepts by faculty. However, this endeavor was prolonged because of some internal changes that were about to occur. Specifically, the Duke University School of Nursing was about to launch its new nurse practitioner curriculum. However, through persistence and the thoughtful approach made by the M-HIP team in selecting mental health concepts for vetting, the school of nursing faculty eventually agreed with the proposed curricular enhancement, although this did not occur within the expected time line.
The M-HIP team consisted of interprofessional faculty and, as such, scheduling time for meetings was difficult in the beginning. However, the addition of adequate administrative support further into the time line of the grant resolved this issue. To promote a sense of equality in the M-HIP team, meeting locations alternated among the buildings of the three programs.
Evidence links mental health and chronic conditions by their interdependence (World Health Organization & Calouste Gulbenkian Foundation, 2014). Therefore, enhancing the competence of future primary care providers in assessing and managing the mental health needs of individuals experiencing chronic conditions is an effective strategy to address and reduce the negative impact of comorbidity. As a result of the training grant received by faculty at Duke University, beginning efforts have been made to integrate mental health concepts in teaching learners about chronic disease management. The method described in this article can be used as a template for faculty in health care disciplines who seek to embark in a similar enhancement of their existing curricula.
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