Journal of Nursing Education

Major Article 

Educating Integrated Family/Psychiatric–Mental Health Nurse Practitioners: Program Development and Evaluation

Polly A. Hulme, PhD, RN, CNP; Julia F. Houfek, PhD, APRN-CNS; Kathryn Fiandt, PhD, APRN-NP; Cecilia Barron, PhD, RN; Susan Muhlbauer, PhD, APRN-NP

Abstract

Background:

This article describes the development, implementation, and outcomes of an integrated family nurse practitioner/psychiatric–mental health nurse practitioner (FNP/PMH-NP) program. The program was designed to help alleviate health professional shortages in rural areas.

Method:

Faculty from both specialties developed a 3-year integrated curriculum, with attention to course sequencing and removing redundancies. Students completed all FNP and PMH-NP specialty courses and 855 clinical hours. Specialty integration occurred during the final semester through faculty-facilitated integrated case studies and clinical preceptorships with dual-certified rural nurse practitioners.

Results:

Thirteen students completed the program between 2006 and 2014. A survey of graduates (75% response rate) demonstrated that most were dual certified, and less than half practiced in rural areas. All were very satisfied with their nurse practitioner role.

Conclusion:

The program successfully prepared graduates to care for patients across the mind–body spectrum in integrated mental health–primary care positions. More work may be needed to market the integrated role and rural practice. [J Nurs Educ. 2015;54(9):493–499.]

Dr. Hulme is Professor, College of Nursing, South Dakota State University, Brookings, South Dakota; and Dr. Houfek is Professor, Dr. Fiandt is Professor and Associate Dean for Transformational Practice and Partnerships, Dr. Barron is Emeritus Associate Professor, and Dr. Muhlbauer is Emeritus Associate Professor, College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska.

This project was funded by a Health Resources and Services Administration grant (D09HP00535). Dr. Fiandt was the Project Director and Dr. Barron was the Co-Project Director.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the University of Nebraska Medical Center College of Nursing.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Polly A. Hulme, PhD, RN, CNP, Professor, College of Nursing, South Dakota State University, Box 2275, Wagner Hall 205, Brookings, SD 57007; e-mail: polly.hulme@sdstate.edu.

Received: September 15, 2014
Accepted: May 14, 2015

Abstract

Background:

This article describes the development, implementation, and outcomes of an integrated family nurse practitioner/psychiatric–mental health nurse practitioner (FNP/PMH-NP) program. The program was designed to help alleviate health professional shortages in rural areas.

Method:

Faculty from both specialties developed a 3-year integrated curriculum, with attention to course sequencing and removing redundancies. Students completed all FNP and PMH-NP specialty courses and 855 clinical hours. Specialty integration occurred during the final semester through faculty-facilitated integrated case studies and clinical preceptorships with dual-certified rural nurse practitioners.

Results:

Thirteen students completed the program between 2006 and 2014. A survey of graduates (75% response rate) demonstrated that most were dual certified, and less than half practiced in rural areas. All were very satisfied with their nurse practitioner role.

Conclusion:

The program successfully prepared graduates to care for patients across the mind–body spectrum in integrated mental health–primary care positions. More work may be needed to market the integrated role and rural practice. [J Nurs Educ. 2015;54(9):493–499.]

Dr. Hulme is Professor, College of Nursing, South Dakota State University, Brookings, South Dakota; and Dr. Houfek is Professor, Dr. Fiandt is Professor and Associate Dean for Transformational Practice and Partnerships, Dr. Barron is Emeritus Associate Professor, and Dr. Muhlbauer is Emeritus Associate Professor, College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska.

This project was funded by a Health Resources and Services Administration grant (D09HP00535). Dr. Fiandt was the Project Director and Dr. Barron was the Co-Project Director.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the University of Nebraska Medical Center College of Nursing.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Polly A. Hulme, PhD, RN, CNP, Professor, College of Nursing, South Dakota State University, Box 2275, Wagner Hall 205, Brookings, SD 57007; e-mail: polly.hulme@sdstate.edu.

Received: September 15, 2014
Accepted: May 14, 2015

The integration of primary care and psychiatric–mental health care holds promise for improving access to care and health outcomes (Kaiser Commission on Medicaid and the Uninsured, 2014). Although advanced practice nurse educators can appreciate and foster an understanding of integrated care within their specialties, integrating both specialties into a single nurse practitioner program is rare. In 2001, faculty from the Family Nurse Practitioner (FNP) and Psychiatric–Mental Health Advanced Practice Nurse (PMH-APN) programs at the University of Nebraska Medical Center (UNMC) began to develop an integrated program. In 2003, the Health Resources and Services Administration (HRSA) awarded a 3-year grant to UNMC to implement the integrated program. The purpose of this HRSA project was to prepare competent advanced practice nurses with comprehensive family and psychiatric–mental health practice skills, particularly for rural practice.

The HRSA project originated from faculty observations that every year several rural FNP graduates applied for postmaster’s certification in the PMH-APN (now PMH-NP) program—and vice versa—to better care for their rural patients. Approximately 671,000 people (36% of the state’s population) live in rural Nebraska (U.S. Department of Agriculture, 2015). Access to health care is problematic in the majority of rural counties in the state, with 66% of Nebraska’s 93 counties designated as family practice shortage areas and 86% as psychiatry and mental health shortage areas (Nebraska Department of Health & Human Services, 2014b).

The UNMC College of Nursing (CON) has long provided accessible and innovative undergraduate and graduate education to rural nursing students. To facilitate this mission, five campuses are spread across the state, leading to its nickname as the “500-Mile Campus.” After graduation, new nurse practitioners benefit from the active support provided by the state professional nursing organizations (e.g., Nebraska Nurse Practitioners [ http://nebraskanp.com/] and the Nebraska Chapter of the American Psychiatric Nurses Association [ http://www.apna.org/i4a/pages/index.cfm?pageid=3407]). These organizations are characterized by high involvement of rural nurse practitioners.

Preparing the HRSA grant application required project faculty to discuss in detail the (a) concepts, (b) content and sequencing of specialty courses, and (c) clinical experiences for each program. During these discussions, the faculty mutually discovered differences in the assumptions and processes used for diagnosing and treating clients, which, at times, were difficult to reconcile. FNP faculty were accustomed to using specific direct methods that have clear objective criteria for arriving at a diagnosis. In contrast, the PMH-NP faculty were accustomed to using clinical interviews based on broad categories (e.g., the categories included in the mental status examination) for arriving at a diagnosis. By their nature, these clinical interviews involve a more circumspective, time-intensive process, resulting in a diagnosis that is more nuanced. This made for lively conversation around the unique product that faculty were jointly describing—an integrated FNP/PMH-NP—who was not merely dual certified but who could provide holistic care across the mind–body spectrum.

The purpose of this article is to describe the development, implementation, and outcomes of the five major objectives for the HRSA project. The first three project objectives addressed the specifics of the integrated program itself—(a) to develop an integrated curriculum, (b) to increase program accessibility via instructional technology, and (c) to facilitate future employment. The fourth project objective targeted student recruitment, enrollment, and retention. Finally, the fifth project objective, described under its own heading, embodied the evaluation plan and outcomes. Six integrated FNP/PMH-NP student cohorts were admitted to the program between 2003 and 2011, with the final student cohort graduating in 2014. Over that time, significant changes occurred in advanced practice nursing education (the proliferation of the Doctor of Nursing Practice [DNP] degree) and national health care policy (the Patient Protection and Affordable Care Act [2010]). These changes enhance the relevance of integrated FNP/PMH-NP programs, as highlighted in the Discussion section of this article. Lessons learned are also summarized in the Discussion section.

Project Objectives, Strategies, and Outcomes

To initiate the process of developing an integrated FNP and PMH-NP curriculum, project faculty first worked to remove redundancies in specialty course content. They mapped the concepts and content for each of their specialty courses but found no significant redundancies. Mapping the concepts and content of their specialties helped project faculty to arrive at a consensus that the quality of their individual programs needed to be maintained and that the content for the integrated program would not be a watered-down version of both programs. This decision making was facilitated by consulting evaluation materials, competencies, and curriculum guidelines from the National Organization of Nurse Practitioner Faculties ( http://www.nonpf.org/) and the Society for Education and Research in Psychiatric–Mental Health Nursing ( http://www.ispn-psych.org/html/serpn.html).

To emphasize the uniqueness of the proposed product, project faculty next developed a new capstone course that would foster graduates who are capable of managing physical and mental health problems concurrently in a holistic manner. The 4 clinical credits for the integrated capstone course included 15 hours of in-class discussion of integrated case studies. Project faculty prepared and facilitated the integrated case studies, designing them to stimulate critical thinking based on knowledge and skills from both specialty areas. Examples of case study topics were (a) anxiety and insomnia, (b) fatigue, (c) headaches and stress, (d) menstrual cycle abnormalities, (e) pelvic pain, (f) unresolved upper respiratory infection, and (g) weakness and forgetfulness.

Clinical experiences for the integrated capstone course were with a preceptor who was certified in both specialties and with a client base that needed both types of care. Early in the project, faculty identified potential preceptors in rural areas who had returned for post-master’s certification in either specialty. Later in the project, graduates from the integrated program who practiced in both specialties became ideal preceptors for the students. Permission was granted from the American Nurses Credentialing Center ( http://www.nursecredentialing.org/) to count the integrated capstone clinical hours as both family and psychiatric–mental health clinical hours. This reduced the total number of clinical hours needed for the integrated students from 1,000 hours (500 hours for each specialty) to 855 hours.

The integrated FNP/PMH-NP program that project faculty designed was achievable in 3 years of full-time study. Table 1 presents the curriculum for this integrated program. The first year was dedicated to the required Master of Science in Nursing (MSN) core courses, as well as advanced pharmacology and advanced pathophysiology. An additional option of completing the core courses in 2 years was available for later cohorts. For the second and third years, the FNP and PMH-NP specialty courses offered each semester were (a) leveled, (b) balanced for number of credit hours, and (c) matched according to pediatric–adolescent or adult–geriatric focus. The total number of required credits equaled 66, which was approximately 15 credits more than the number of credits required for just one specialty.

Integrated Family Nurse Practitioner/Psychiatric–Mental Health Nurse Practitioner Curriculum for a Health Resources and Services Administration Project (2003–2006)

Table 1:

Integrated Family Nurse Practitioner/Psychiatric–Mental Health Nurse Practitioner Curriculum for a Health Resources and Services Administration Project (2003–2006)

The next project objective was to increase program accessibility through instructional technology. Previously, the FNP faculty had received a HRSA grant to increase rural students’ access to the FNP curriculum through emerging distance-learning technology. Therefore, the FNP faculty’s prior experience with using technology and distributive education methods to remove disparities between rural and urban students’ learning experiences provided a launching point for this objective. To keep abreast with cutting-edge distance learning technology, a part-time information technology specialist salary was budgeted into the HRSA project for the integrated program. During the early years of the integrated program, synchronous classes were conducted via interactive satellite television available at each CON campus. Later, Internet Protocol video and Adobe® Connect allowed remote rural students to attend synchronous classes from home. Additional distance-learning modalities were an online course management system, narrated slides, podcasts, synchronous chat rooms, asynchronous discussion boards and wikis, desktop videoconferencing, and online quizzes and examinations.

To facilitate future employment (the third project objective), project faculty strategically utilized their broad network of relationships within Nebraska’s health care system for preceptors and employment resources. They helped students with encountering potential employers before graduating by placing them in a variety of clinical experiences. Further, a program policy was adopted that required students to complete a minimum number of service hours. Service opportunities include the CON’s own primary care clinic; an UNMC interprofessional, student-run clinic; federally funded rural and urban health care sites; and community-based mental health centers.

An additional strategy for facilitating future employment was to assign the students in the integrated capstone course with the tasks of creating a professional portfolio and a comprehensive business plan. The portfolio includes a polished résumé, a list of coursework completed, a description of clinical preceptorships, a brief essay on the student’s ideal job description, skills and procedures competencies, and samples of scholarly work. Students wrote the business plan for an integrated practice of their choice. The assignment was structured to allow students to showcase their skills and knowledge of the business side of practice, which included topics such as billing, financing, and marketing.

For the fourth project objective, the project faculty targeted 21 students for recruitment, enrollment, and retention during the 3-year, grant-funded period (2003–2006). This number was based in part on survey results from 272 recent UNMC baccalaureate nurse graduates. The survey was conducted in 2002 in preparation for the HRSA grant application. It described the proposed integrated program and asked about the recipients’ interest level. Definite interest was indicated by 36 respondents (65% were rural), and somewhat interested was indicated by 100 respondents (66% were rural). An additional 21 graduates from the proposed integrated program would have boosted the total number of FNPs and PMH-NPs in the state at that time by 16%.

When the project was funded by HRSA, project faculty worked with the CON recruiter and contacted health care agencies via print and electronic media across the state to market the program to nurses. Qualified applicants were interviewed by a member from each specialty to assess their appropriateness for the integrated program, their understanding of its rigorous course load, and their commitment to rural and other under-served populations.

To promote student retention, the policies and practices at the CON regarding admission, progression, and graduation were reviewed by project faculty and were found to be supportive. In addition, project faculty reviewed the CON’s graduate student orientation content and process. Orientation materials included information on the online course management system; the use of e-mail and other communication media; library resources; methods for contacting course faculty, advisers, and the technology specialists for help; local campus learning resource centers; and student services. Information on successful distance learning became particularly important when new technology allowed remote rural students to attend synchronous classes from home.

The project faculty fell short of their goal of recruiting, enrolling, and retaining 21 students during the 3-year, grant-funded period. During the first 2 years, faculty enrolled 11 students in two cohorts, of which seven were retained. During the third year, admission to the integrated program had to be suspended due to course scheduling conflicts beyond the project faculty’s control. After grant funding ended, an additional 16 students were enrolled in four cohorts, with the last cohort admitted in 2011 and graduated in 2014. After 2011, admission to the integrated program was placed on hold during the CON’s transition from the MSN degree to the DNP degree.

The number of students enrolled in each of the six cohorts according to graduation year is found in Table 2. As can be seen in Table 2, 13 of the 27 enrolled students graduated from the integrated program, for a retention rate of 48%. Of the 14 students who were not retained, the majority transferred to the FNP program (seven students) or the PMH-NP program (two students) and graduated from UNMC. Thus, 30% of enrolled students dropped out of the integrated program but still completed the FNP program or the PMH-NP program. Most nonretained students left the integrated program before beginning the specialty courses. Although formal exit interviews were not conducted, discussion with students when they left the integrated program indicated that family issues or a lack of time or resources to complete the program were their main reasons for leaving.

Students Enrolled in and Graduated From the Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Program by Cohort and Graduation Year

Table 2:

Students Enrolled in and Graduated From the Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Program by Cohort and Graduation Year

Evaluation Plan and Outcomes

The final project objective was to evaluate the project’s overall quality and effectiveness. The CON’s Director of Continuing Education and Evaluation assisted project faculty with developing an evaluation plan. The evaluation plan changed over the years in which the integrated program was offered due to fewer resources at the conclusion of the grant-funded years and changes in CON policies. Formative evaluation methods included faculty and staff project meetings and student course evaluations. Summative evaluation methods consisted of written comprehensive examinations, an exit focus group, an MSN exit survey, and a final survey of graduates conducted in the fall of 2013.

Faculty and Staff Project Meetings

During the grant-funded years (2003–2006), faculty and staff project meetings were held monthly. After the grant funding ended, project meetings were held as needed. At the meetings, the progress of the strategies associated with each objective was discussed and evaluated for achievement. Typical topics of discussion included course work planning, technology updates, marketing opportunities for students and the integrated FNP/PMH-NP role, recruitment issues, applicant status, student progression, and policy changes in relevant national agencies and organizations. Minutes were kept to document program processes.

Student Course Evaluations

Because the integrated students took the same specialty courses as the students enrolled in the FNP program and the PMH-NP program, project faculty were unable to extract course evaluation data from only the integrated students. One exception was data from the integrated capstone course, which had its own course number. Although faculty highly encouraged student feedback on the integrated capstone course evaluation, completion rates were low. One possible explanation is the low faculty-to-student ratio for the integrated case study sessions. Faculty encouraged and responded to student feedback at these sessions, which may have lessened the perception that additional evaluation was necessary. Another possible explanation is learner fatigue related to the integrated program’s intensity during the final semester. From the available responses, satisfaction with the integrated capstone course was evident, with a student ranking of agree or better on scale items.

Despite being unable to extract course evaluation data for the integrated students in the specialty courses, institutional systems were in place for using course evaluations to maintain high course quality. The CON’s standardized procedure for responding to student course evaluations was to have faculty document the ways in which the evaluations were used to monitor the quality of their courses and identify areas for improvement. Areas of improvement automatically included any items in which less than 80% of students endorsed agree or highly agree on the scale items, as well as any issue cited by multiple students. All implemented changes based on student course evaluations were examined for effectiveness the next time the course was offered. As a further safeguard for quality, the CON’s Graduate Affairs Committee reviewed student course evaluations annually.

Written Comprehensive Examinations

Integrated students who graduated between 2006 and 2011 completed written comprehensive examinations, which was a requirement for the MSN degree during those years. The comprehensive examination consisted of three integrated case studies (health promotion, pediatric acute, and adult chronic), with accompanying questions that required students to integrate their knowledge from both specialties. A fourth topic assessed student understanding of the integrated role and their ability to describe clinical, regulatory, and financial considerations for integrated practice in the rural setting. All integrated students passed their comprehensive examinations on the first attempt.

Exit Focus Group

The director of continuing education and evaluation led an exit focus group with the first integrated cohort. All students in this cohort participated. Questions were formulated by the project faculty prior to the session. Student opinions were elicited on such topics as the ways in which they saw themselves as being different from students in either specialty alone, the skills they had gained, the balance of integrated coursework, and the benefits of completing the integrated program. The results revealed that students perceived problems relating to rule changes, inconsistencies, and lack of timely information, which they attributed to being the first cohort. In addition, they believed that billing for dual practice services was not sufficiently covered. Overall, the students were uncertain about their employment prospects and whether the benefit of having completed the integrated program outweighed the costs (e.g., increased time, energy, monetary expenditures).

In discussing the focus group results, the project faculty believed that the stress of completing the integrated program while working may have flavored the students’ comments. When designing the curriculum, project faculty envisioned that students would not work due to the intense course load, similar to postbaccalaureate health professional trainees enrolled in other disciplines. For those who needed it, graduate assistantships were available for modest financial support. As the first cohort progressed through the program, project faculty became aware that the intense program placed students in a catch-22 situation in regard to outside RN work. In general, the younger, less experienced students wanted to work to gain more experience, whereas the older, more experienced students needed to work because of family responsibilities and an established lifestyle.

Nonetheless, project faculty carefully considered the opinions voiced by the first cohort during the exit focus group. Efforts were made to provide more information about billing for patient services for both specialties. Having become better aware of the sources of student stress, faculty provided more emotional support and encouragement with subsequent cohorts. They worked with students to make the integrated program doable by increasing flexibility where feasible and by collaborating with student-preferred rural preceptors for integrated clinical hours.

MSN Exit Survey

An electronic MSN exit survey was available for integrated students who graduated in 2011. Three of the four students in this fourth cohort responded. Overall, the integrated students were positive about their graduate student experience. For example, of the 19 survey items about how well the CON’s terminal MSN objectives were met, 15 items were endorsed by the students with a 4 or above on a scale of 1 (the least positive response) to 5 (the most positive response). MSN exit survey data for the 2013 and 2014 cohorts were not available because they comprised only one student each.

Final Survey of Graduates

A final summative evaluation of the project’s quality and effectiveness was conducted in fall 2013. Two project faculty (P.A.H., J.F.H.) designed and administered an electronic survey to determine the graduates’ (a) certification(s) held, (b) specialty for which they were hired, (c) practice characteristics, (d) role satisfaction, and (e) beliefs about the value of the integrated program. An additional set of questions was added to elicit the integrated graduates’ opinions on elements needed to sustain an integrated FNP/PMH-NP practice in rural areas. Those questions were developed based on faculty experience and the literature (e.g., Roberts et al., 2012). After receiving UNMC Institutional Review Board approval, an invitation to participate and a link to the survey were sent to the e-mail addresses of former integrated students who had graduated by 2013 (N = 12).

Nine integrated graduates responded to the survey (75% response rate). All nine respondents reported being certified as FNPs, with an additional seven certified as PMH-NPs, thus being dual certified. One third of respondents were hired for both specialties in their main employment. One third of respondents reported billing for both specialties. More than half of the respondents (n = 5) reported that they were able to practice both specialties in their primary employment, and more than half (n = 5) had more than one nurse practitioner job. Although all respondents were FNP certified, only five practiced in primary care. Of those certified as PMH-NP (n = 7), four were providing both psychiatric–mental health medication management and psychotherapy. The majority of respondents had remained in Nebraska (n = 7), but less than half of the respondents (n = 4) practiced in rural areas. All respondents reported being very satisfied to extremely satisfied with their nurse practitioner role. Two thirds of respondents stated that they would complete the integrated program if they had a chance to do it all over again.

Results for the elements needed to sustain an integrated practice in rural areas are shown in Table 3. The respondents rated all of the elements as moderately important or better, except for hospital privileges, which was rated as somewhat important. Of particular importance to the respondents was the quality of life elements, such as time off or time away from one’s practice.

Elements Needed to Sustain an Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Dual Certification in Rural Practice as Rated by the Respondents (n = 9)a

Table 3:

Elements Needed to Sustain an Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Dual Certification in Rural Practice as Rated by the Respondents (n = 9)

Discussion

At this time of health care reform in the United States, integrated health care models have become policy (Mann, 2012). Rural populations with health professional shortages are particularly in need of integrated service delivery (Nebraska Department of Health & Human Services, 2014a). Specialization exacerbates the problems with access to care in rural areas and can have a negative effect on health outcomes. For example, primary care providers are essential for delivering psychiatric–mental health care in rural and underserved areas. However, even common disorders such as major depression are frequently underrecognized and undertreated by primary care providers (Craven & Bland, 2013; Vermani, Marcus, & Katzman, 2011; Xierali et al., 2013). Further, the primary care needs of individuals with psychiatric–mental health disorders are often poorly met, resulting in greater chronic disease morbidity and mortality (Druss, Zhao, Von Esenwein, Morrato, & Marcus, 2011; Lester, Tritter, & Sorohan, 2005).

Various models for integrating primary care and psychiatric–mental health care services have been described in the literature (Fisher & Dickinson, 2014; Heath, Wise Romero, & Reynolds, 2013), with merged practice as the ultimate goal (Heath et al., 2013). However, not all agree that clinical practice itself should or can be merged. For example, McCabe and Macnee (2002) indicated that dual practice is unrealistic and that it is impossible to maintain competency in both specialties. The outcomes of the current project provide evidence to the contrary. In addition, with the Commission on Collegiate Nursing Education’s requirement of a minimum of 1,000 clinical practice hours for DNP program accreditation (American Association of Colleges of Nursing, n.d.), innovative programs that meet rural health care needs, including integrated practice models, are likely to gain attention.

The 2013 survey of the graduates, as described in the Evaluation Plan and Outcomes section, provided supportive evidence of the integrated program’s quality and effectiveness. The respondents’ overall positive responses contrasted with the problems expressed by the first cohort at the time of the exit focus group. Of particular note was the high number of respondents who maintained dual certification and their unanimous satisfaction with their role as a nurse practitioner. Of concern was the reporting of more than one nurse practitioner job for many of the respondents, which may indicate that multiple jobs are required to maintain dual certification.

Another concern was that less than half of the respondents reported practicing in rural areas. Although the integrated program was conceived as a unique method for increasing access to care in the rural areas, the graduates faced barriers to rural practice peculiar to their training. As gleaned from the 2013 graduate survey and anecdotally from students’ experiences in seeking rural employment, the barriers included (a) local unfamiliarity with or resistance to the integrated role and (b) attractive job offers and living conditions in metropolitan areas.

A challenge for project faculty was meeting the project goals for the number of students enrolled and retained in the integrated program. Enrolled integrated students who dropped out of the program did so mostly while they were taking core courses, before project faculty had interacted with them. In retrospect, preclinical get-togethers for information sharing would have been a good tactic to address this problem, as would have been preclinical dual-certified nurse practitioner shadowing experiences. Although some students dropped out of school completely, most decided that they would rather concentrate on one specialty. To discourage decampment to a single speciality, project faculty initially considered requiring students to reapply to the program specialty of choice but eventually decided to let the students transfer without reapplication.

Some additional lessons were learned. Working through the FNP and PMH-NP curricula separately for three semesters and then integrating the content during the integrated capstone course proved more difficult for the students than project faculty anticipated. First, students were stressed by the extra-heavy course load. Although this was discussed during admission interviews, the reality of the course load could not be appreciated until it was actually experienced. Project faculty specifically stated during admission interviews that engaging in outside employment would be almost impossible during clinical course work. However, faculty could not mandate how much students worked after starting the program. Second, it was difficult for students to reconcile the differences in approach and content for the two specialties. This was particularly revealed when they started the integrated capstone course. The integrated case studies and integrated clinical experiences proved essential for discussion on these differences and for facilitating integrated practice.

Conclusion

The project faculty and graduates of an integrated FNP/PMH-NP program established that it is both possible and beneficial (on personal and societal levels) to become a dual-certified, holistically skilled advanced practice nurse who provides health care across the mind–body spectrum. It was also demonstrated that an integrated program requires a high investment of both faculty and students. A unique feature of the program was the integrated capstone course, which fostered integration of the two specialties and decreased duplication of clinical hours. As graduate nursing education for advanced practice embraces the DNP degree, it is timely to consider the feasibility of integrated practice models that address (a) holistic patient care that meets both physical and mental health needs and (b) the persistent shortages of health professionals in rural areas.

References

  • American Association of Colleges of Nursing. (n.d.). Frequently asked questions: DNP programs & CCNE accreditation. Retrieved from http://apps.aacn.nche.edu/Accreditation/dnpFAQ.htm
  • Craven, M. A. & Bland, R. (2013). Depression in primary care: Current and future challenges. Canadian Journal of Psychiatry, 58, 442–448.
  • Druss, B.G., Zhao, L., Von Esenwein, S., Morrato, E.H. & Marcus, S.C. (2011). Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Medical Care, 49, 599–604. doi:10.1097/MLR.0b013e31820bf86e [CrossRef]
  • Fisher, L. & Dickinson, W.P. (2014). Psychology and primary care: New collaborations for providing effective care for adults with chronic health conditions. American Psychologist, 69, 355–363. doi:10.1037/a0036101 [CrossRef]
  • Heath, B., Wise Romero, P. & Reynolds, K.A. (2013). A standard framework for levels of integrated healthcare. Washington, DC: SAMHSA-HRSA Center for Integrated Health Solutions. Retrieved from http://www.integration.samhsa.gov/resource/standard-framework-for-levels-of-integrated-healthcare
  • The Kaiser Commission on Medicaid and the Uninsured. (2014, February12). Integrating physical and behavioral health care: Promising Medicaid models [Issue brief]. Menlo Park, CA: Henry J. Kaiser Family Foundation. Retrieved from http://kff.org/report-section/integrating-physical-and-behavioral-health-care-promising-medicaid-models-issue-brief/
  • Lester, H., Tritter, J.Q. & Sorohan, H. (2005). Patients’ and health professionals’ views on primary care for people with serious mental illness: Focus group study. BMJ, 330, 1122–1126. doi: http://dx.doi.org/10.1136/bmj.38440.418426.8F doi:10.1136/bmj.38440.418426.8F [CrossRef]
  • Mann, C. (2012, July10). Integrated care models. State Medicaid director letter [SMDL# 12-001 ICM# 1]. Retrieved from http://www.medicaid.gov/search.html?q=integrated%20care
  • McCabe, S. & Macnee, C.L. (2002). Weaving a new safety net of mental health care in rural America: A model of integrated practice. Issues in Mental Health Nursing, 23,263–278. doi:10.1080/016128402753543009 [CrossRef]
  • Nebraska Department of Health & Human ServicesOffice of Rural HealthRural Health Advisory Commission (2014a). Nebraska Rural Health Advisory Commission’s annual report and rural health recommendations. Retrieved from http://dhhs.ne.gov/publichealth/Pages/hew_orh_rhac.aspx
  • Nebraska Department of Health & Human ServicesOffice of Rural Health. (2014b). State primary care and mental health shortage area list. Retrieved from http://dhhs.ne.gov/publichealth/Pages/hew_orh_samaps.aspx
  • Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).
  • Roberts, C., Daly, M., Kumar, K., Perkins, D., Richards, D. & Garne, D. (2012). A longitudinal integrated placement and medical students’ intentions to practise rurally. Medical Education, 46, 179–191. doi:10.1111/j.1365-2923.2011.04102.x [CrossRef]
  • U.S. Department of Agriculture Economic Research Service. (2015). State fact sheets: Nebraska, 2013 data. Retrieved from http://www.ers.usda.gov/data-products/state-fact-sheets/state-data.aspx?StateFIPS=31&StateName=Nebraska
  • Vermani, M., Marcus, M. & Katzman, M.A. (2011). Rates of detection of mood and anxiety disorders in primary care: A descriptive, cross-sectional study. The Primary Care Companion for CNS Disorders, 13(2), PCC.10m01013. doi:10.4088/PCC.10m01013 [CrossRef]
  • Xierali, I.M., Tong, S.T., Petterson, S.M., Puffer, J.C., Phillips, R.L. Jr.. & Bazemore, A.W. (2013). Family physicians are essential for mental health care delivery. Journal of the American Board of Family Medicine, 26, 114–115. doi:10.3122/jabfm.2013.02.120219 [CrossRef]

Integrated Family Nurse Practitioner/Psychiatric–Mental Health Nurse Practitioner Curriculum for a Health Resources and Services Administration Project (2003–2006)

Year/Semester/Course NameCreditsClinical Hours
Year one: Fall
  Graduate Statistics3
  Knowledge Development in Nursing3
  Pathophysiology for Advanced Practice Nurses3
  Clinical and Role Issues for the Nurse Practitioner1
Semester total10
Year one: Spring
  Advanced Pharmacology for Advanced Practice Nurses3
  Advanced Practice Nursing in the Health Care Delivery System3
  Research Methods for Advanced Nursing Practice3
  Community-Based Care for Vulnerable People2
Semester total11
Year two: Fall
  Advanced Health Assessment and Health Promotion6
  Counseling Models in Advanced Psychiatric–Mental Health Nursing345
  Neuroscience Foundation for Advanced Practice Nursing2
  Research in Clinical Nursing1
Semester total1245
Year two: Spring
  Primary Health Care of Older Families6135
  Advanced Psychiatric Mental Health Nursing With Adults490
  Research in Clinical Nursing1
Semester total11225
Year three: Fall
  Primary Health Care of Younger Families7180
  Advanced Psychiatric–Mental Health Nursing With Children and Adolescents490
  Research in Clinical Nursing1
Semester total12270
Year three: Spring
  Advanced Integrated Primary Care and Psychiatric–Mental Health Nursing5180
  Practicum in Advanced Psychiatric–Mental Health Nursing3135
  Research in Clinical Nursing2
Semester total10315
Program total66855

Students Enrolled in and Graduated From the Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Program by Cohort and Graduation Year

Student StatusCohort (Graduation Year)

1 (2006)2 (2007)3 (2009)4 (2011)5 (2013)6 (2014)
Enrolled in integrated program657522
Graduated from:
  Integrated program520411
  FNP program only1221a1
  PMH-NP program only11
Dropped out of school14

Elements Needed to Sustain an Integrated Family Nurse Practitioner (FNP)/Psychiatric–Mental Health Nurse Practitioner (PMH-NP) Dual Certification in Rural Practice as Rated by the Respondents (n = 9)a

ElementMean (SD)
1. Hospital privileges2.67 (1.41)
2. Salary that is competitive with metropolitan areas3.78 (1.48)
3. Location in a rural area that can draw enough patients to practice in both specialties3.78 (0.83)
4. Availability of a collaborating physician in each specialty3.56 (1.51)
5. Ability to refer to the collaborating physician(s) or other referral sources3.33 (1.87)
6. Ability of the office to bill for mental health services3.78 (1.39)
7. Patients who are receptive to mental health services in a primary care setting3.44 (1.13)
8. Patients who are receptive to primary care services in a mental health setting3.22 (1.20)
9. Patients who are receptive to innovative models that facilitate the integrated FNP/PMH-NP role3.56 (1.13)
10. Other providers in the practice who are receptive to innovative models that facilitate the integrated FNP/PMH-NP role3.78 (1.09)
11. Office staff in the practice who are receptive to innovative models that facilitate the integrated FNP/PMH-NP role3.78 (1.20)
12. Collegial relationships with other health care providers in the practice setting4.22 (1.20)
13. Time off or time away from one’s practice4.22 (1.39)
14. Quality of personal life in the practice location4.22 (1.39)

10.3928/01484834-20150814-03

Sign up to receive

Journal E-contents