Journal of Nursing Education

Educational Innovations 

Partnering for a Sustainable Interprofessional Psychiatric Mental Health Nurse Practitioner Education Curriculum

Barbara L. Peterson, PhD, PMHCNS-BC; Amy L. Pittenger, PhD, PharmD; Merrie J. Kaas, PhD, APRN, PMHCNS-BC, FAAN; Jody L. Lounsbery, PharmD, BCPS

Abstract

Background:

The World Health Organization recommends that health care educators create a collaborative and practice-ready workforce. Focused interprofessional education (IPE) promotes collaborative practice, yet few examples of how to develop sustained IPE and clinical partnerships exist. Mental health care professionals competent in their specialty and prepared for interprofessional collaboration are needed to treat complex mental health needs of patients.

Method:

Doctor of Nursing Practice Psychiatric Mental Health Nurse Practitioner (PMHNP) faculty partnered with College of Pharmacy faculty to create didactic, clinical, and simulation coursework and IPE competencies within PMHNP courses. Students developed skills about providing interprofessional mental health care.

Results:

Recommendations for faculties include: embrace the value of interprofessional faculty partnerships; plan for time, money, motivation, and recognition needed for sustainable IPE; and design courses that become part of the fabric of the curricula.

Conclusion:

Embedding IPE into PMHNP curricula creates increased faculty satisfaction and positive feedback from students and clinical sites. [J Nurs Educ. 2019;58(12):723–727.]

Abstract

Background:

The World Health Organization recommends that health care educators create a collaborative and practice-ready workforce. Focused interprofessional education (IPE) promotes collaborative practice, yet few examples of how to develop sustained IPE and clinical partnerships exist. Mental health care professionals competent in their specialty and prepared for interprofessional collaboration are needed to treat complex mental health needs of patients.

Method:

Doctor of Nursing Practice Psychiatric Mental Health Nurse Practitioner (PMHNP) faculty partnered with College of Pharmacy faculty to create didactic, clinical, and simulation coursework and IPE competencies within PMHNP courses. Students developed skills about providing interprofessional mental health care.

Results:

Recommendations for faculties include: embrace the value of interprofessional faculty partnerships; plan for time, money, motivation, and recognition needed for sustainable IPE; and design courses that become part of the fabric of the curricula.

Conclusion:

Embedding IPE into PMHNP curricula creates increased faculty satisfaction and positive feedback from students and clinical sites. [J Nurs Educ. 2019;58(12):723–727.]

Doctor of Nursing Practice Psychiatric Mental Health Nurse Practitioner (PMHNP) faculty partnered with College of Pharmacy (COP) faculty to create didactic, clinical, and simulation coursework and interprofessional education (IPE) competencies within PMHNP courses. Students developed skills about providing interprofessional mental health care. Recommendations for other faculties include: embracing the value of interprofessional faculty partnerships; planning for the time, money, motivation, and recognition needed for sustainable IPE; and designing courses that become part of the fabric of the curricula. Embedding IPE into PMHNP curricula can create increased faculty satisfaction and positive feedback from students and clinical sites.

Background

Health care professional students have traditionally been taught in disciplinary silos. Yet, the complex health needs of psychiatric patients necessitate that professionals are competent in their specialties and are prepared for interprofessional collaboration. The World Health Organization (WHO) recommends that health care educators should create a “collaborative practice-ready workforce” in education and practice (WHO, 2010, p. 10). New models of psychiatric nursing graduate education that include real-world IPE activities and authentic collegial working relationships with other health care professionals are needed to meet the challenges of caring for complex psychiatric patients.

Mental health disorders are the leading cause of disability in the United States and Canada, and people with serious mental illness die an average of 25 years earlier than the general population (WHO, 2013). Mental health disorders and medical illnesses often co-exist and cause accumulating negative effects on physical health over the lifetime (Scott et al., 2016). No single provider alone can address the complex health care needs of mental health patients. Interprofessional collaboration is based on the premise that when clinical providers integrate their care with other providers and patients, they can better address the multiple factors that influence the health of individuals, families, and communities (Interprofessional Education Collaborative Expert Panel [IPEC], 2011). Shifting the culture of mental health care away from the “silo culture” toward collaboration is a paradigm shift best achieved while students are establishing their professional identity.

Challenges to IPE in Health Care Professions

Examples of innovative IPE initiatives are found in the literature, yet few of these initiatives were sustained over time; there are even fewer examples of initiatives that met their original goals (Cox & Naylor, 2013; d'Avray & McCrorie, 2011). Numerous barriers to creating sustained interprofessional IPE have been identified in the literature. As outlined in the review by Reeves et al. (2016), lack of organizational support and funding for IPE efforts, including funding for faculty workload, can thwart interprofessional education and training efforts. Lack of faculty preparation to teach IPE and absence of expert interprofessional clinical role models also hinder faculty willingness to champion IPE (Abu-Rish et al., 2012; d'Avray & McCrorie, 2011). Already packed curricula often force IPE activities to be marginalized or seen as superfluous. Logistical problems such as conflicting academic calendars across schools within the university, lack of opportunities for faculty to get to know and work with each other, and the lack of adequate classroom space are systems issues that can confound even the best IPE efforts (d'Avray & McCrorie, 2011; Reeves et al., 2016). Other challenges to IPE may be pedagogical differences among faculty from different specialty areas and the lack of a shared language about what constitutes interprofessional education (d'Avray & McCrorie, 2011).

Despite barriers that threaten the success of IPE efforts, there is agreement that IPE is essential for preparing mental health care practitioners for collaborative practice to improve the quality of care for complex patients (Lapkin, Levett-Jones, & Gilligan, 2013). PMHNP programs can benefit from curricula that incorporate discipline-specific education along with interprofessional learning opportunities. Curricular changes that include IPE are needed to prepare students to provide safe, high-quality, and holistic care for people with mental illness (Institute of Medicine, 2015; WHO, 2010). Few examples in the literature describe how to develop academic and mental health clinical partnerships dedicated to creating sustainable IPE models for future workforce needs.

The purpose of this article is to provide an example of processes and implementation of IPE curricula that successfully overcame the well-documented challenges to implementing sustained IPE curricular change. This article also provides recommendations for faculty who will develop IPE curricula and clinical partnerships for their professional health care students in the future.

Creating an Innovative Approach to Doctor of Nursing Practice PMHNP and PharmD Education

An innovative and sustained IPE curriculum was implemented at the University of Minnesota School of Nursing (SON) Doctor of Nursing Practice (DNP) PMHNP specialty program and the COP Doctor of Pharmacy (PharmD) program. Curriculum changes were developed during two sequential Advanced Nursing Education grants funded by the Health Resources and Services Administration (HRSA) from 2013 through 2019. In addition to providing salary support for faculty workload efforts to make curricular changes proposed in the grants, HRSA funding was used to enhance interprofessional education activities and create collaborative, integrated clinical practices at two community mental health agencies. A major aim of the HRSA grants was to prepare DNP PMHNP and PharmD students for interprofessional collaborative mental health practice and to work with our community mental health clinical partners to translate classroom IPE into clinical practice.

The University of Minnesota SON DNP PMHNP specialty area requires 3 years of full-time study, including five semesters of clinical specialty didactic and clinical courses. DNP PMHNP students are required to complete 960 hours of supervised clinical learning during five specialty semesters. A hybrid model of teaching is used in which most of the student learning is performed online and students come to campus 4 to 5 days per semester to learn together in the classroom and in simulations. DNP PMHNP students are taught holistic psychiatric assessment and treatment, including pharmacological interventions, integrative therapies, as well as individual, group, and family psychotherapies across the life span.

The University of Minnesota COP program created an integrated interprofessional mental health focus area in which third-year pharmacy students elected to complete courses in mental health care and psychopharmacology and least one 5-week psychiatric-focused clinical rotation block. Fourth-year pharmacy students at the University of Minnesota COP complete 45 weeks of full-time (40 hours per week) clinical rotation during the fourth year of the program, and for those interested in psychiatric pharmacy, this rotation block is with a pharmacist who is certified in psychiatric pharmacy. Third-year PharmD students interested in augmenting both interprofessional and mental health knowledge and skills enrolled in two DNP PMHNP specialty courses: Foundations for Integrative Mental Health and Psychiatric Advanced Nursing Practice in the fall semester, and Assessment and Management of Psychiatric Disorders for Advanced Practice Psychiatric Mental Health Nursing in the spring semester.

The University of Minnesota SON and COP shared a mutual commitment to IPE, and each program has a strong record of administrative commitment to IPE as evidenced by shared IPE elective courses throughout the university. The University of Minnesota Academic Health Center houses The National Center for Interprofessional Practice and Education, which provides leadership, evidence, and resources to guide the use of IPE and collaborative practice. Despite university, program, and faculty commitment to IPE, challenges to successful integration of SON and COP coursework threatened its success. For example, the DNP PMHNP specialty curriculum employed a hybrid model of learning, whereas pharmacy courses were taught face-to-face and on two different campuses, creating misalignment in teaching strategies and scheduling class times. Differing registration policies and academic calendars within the two specialty units created misaligned student schedules. Because these and other challenges to successful IPE were described in the literature, we intentionally prepared the faculty and clinical sites for interprofessional experiences.

To prepare faculty for interprofessional teaching, grant-funded SON and COP faculty participated in National Center workshops and conferences, which helped us to develop a common language and begin to design an IPE course and clinical experiences. SON and COP IPE faculty met frequently and regularly to address and work through the grant implementation challenges and, in doing so, developed a deeper understanding and mutual value for each other's pedagogical perspectives and teaching expertise. Creative problem solving, as well as an unwavering belief in the value of IPE on the part of faculty from both colleges, was needed to reach our IPE curricular goals. To prepare the clinical sites for interprofessional teaching and practice, a number of activities were undertaken, including (a) assessment of organizational readiness for interprofessional practice and education using the InSITE tool (Sick, 2013); (b) follow-up discussions about the implications for implementing IPE clinical experiences at each site; (c) clinical staff and faculty participation in workshops and conferences sponsored by the National Center to learn strategies for implementing IPE experiences in a clinical site; (d) in-services for interprofessional preceptors; and (e) active participation of administrative and clinical decision makers from both clinical sites in monthly HRSA team meetings where clinical and educational IPE challenges were discussed and solved.

Educational Design Strategies to Meet IPE Curricular Goals and Overcome Challenges

The overarching goal was to partner with pharmacy colleagues to develop and embed IPE curriculum into existing DNP PMHNP courses and open the courses to pharmacy students enrolled in the Integrated Interprofessional Mental Health focus area. Through amplifying interprofessional aspects into our existing course learning objectives, we essentially wove the concepts and competencies of IPE into the fabric of our foundational psychiatric nursing courses. The first-semester DNP PMHNP specialty didactic course learning goals included understanding integrative mental health assessment, analyzing the impact of social determinants of health on mental health, and developing therapeutic interviewing skills for the purpose of eliciting and understanding the patient's health story. The second-semester DNP PMHNP specialty didactic course learning goals focused on understanding psychiatric disorders, conducting a holistic assessment and making a psychiatric diagnostic, and developing a patient-centered treatment plan. To meet the added IP learning goals of the two courses, PMHNP and PharmD faculty developed competency-based interprofessional learning experiences based on the IPEC Core Competencies for Interprofessional Collaborative Practice (IPEC, 2011). For example, the IPEC competencies of communication and ethics and values were highlighted throughout course content about social determinants of health by using multimedia modules that portrayed realistic patient examples. PMHNP and PharmD students together grappled with ethical dilemmas and personal values from a patient-centered approach rather than a discipline-specific approach as they created “mind maps” that illustrated the impact of social determinants of health in underserved populations. Working in interprofessional dyads and small groups, students developed the IPEC competency of teamwork as they assessed and prioritized psychiatric disorders and developed holistic treatment plans using case-based learning and a series of online video clips of patients with psychiatric problems. Throughout the two semesters, students developed IPEC competencies in understanding their roles and responsibilities in providing interprofessional mental health care through case-based learning, simulations, video chats, and online and in-person discussions. Collegiality and trust were built over time and were fostered through intentionally creating consistent small groups for students in both cohorts to learn together throughout the two semesters of coursework.

The PMHNP and PharmD faculty created six on-campus simulation experiences across two semesters. These simulations used standardized patients portraying mental health problems and students practiced collaborative, interprofessional interviewing of patients. Creating multiple simulation experiences with unfolding cases encouraged scaffold learning as students progressed from basic to advanced interviewing and assessment skills with increasingly complex psychiatric and medical patient problems. Students were intentionally placed in consistent, interprofessional teams to foster trust in what each discipline brought to the case analysis and promote open communication and team collaboration to develop recommendations for each simulated patient case. Each simulation session was 3 hours in length and started with an overview of the simulation agenda, an introduction of learning goals, and a centering exercise (e.g., relaxation breathing exercises, guided imagery, aromatherapy). Students met in their assigned interprofessional teams for a preinterview huddle to plan and prioritize their goals for the interview and discuss their roles and responsibilities. Following each simulation, students participated in a large-group debriefing session designed to provide an opportunity for students to reflect on the simulation, discuss what went well, and identify opportunities for improvement. Debriefing occurred using the debriefing with good judgement approach (Rudolph, Simon, Rivard, Dufresne, & Raemer, 2007). All simulations were captured on video, and students completed a written reflection and analysis about their experience after reviewing the video. Student reflections consistently identified growing confidence in their collaboration skills and the benefits of team-based care.

Responsibility for developing course content and its revision and weekly publishing of online modules remained with the DNP PMHNP faculty; however, responsibility for on-campus teaching, student discussion and feedback, and assignment grading was shared by nursing and pharmacy faculty. Team-building exercises, assignments, and simulations were designed to help students gain skills in communication and collaboration. Students addressed challenges to interprofessional collaboration and discovered how differences in professional roles and responsibilities could be an asset rather than a drawback.

Anchoring Coursework to Clinical Experiences to Sustain IPE Efforts

A key aspect of our HRSA grants and IPE curricular design was the inextricable link between the didactic courses and clinical experiences. The DNP PMHNP specialty didactic and clinical courses are taught concurrently, which offers immediate opportunity for students to practice interprofessional collaborative care in their clinical placements. To highlight the importance of interprofessional practice, DNP PMHNP faculty added clinical learning objectives about interprofessional collaboration to our clinical evaluation tool. Clinical faculty and preceptors anecdotally identified that students were highly prepared and motivated to apply interprofessional skills gained from their didactic experiences in their psychiatric clinical rotations.

Our community clinical partners participating in the HRSA grant helped to translate interprofessional classroom learning into interprofessional clinical practice for students placed in their agencies. One DNP PMHNP faculty member and one PharmD faculty member were assigned to the clinical partner sites 1 day per week with the goal of developing IP clinical experiences at each site with the clinical IPE preceptors. An important factor in the sustainability of the IPE clinical experience was the creation of a Clinical Education Coordinator (CEC) position at each site. Each CEC expanded the clinical IPE curriculum to include all health professional students and prepared clinical staff across all specialty areas to be interprofessional preceptors.

Clinical staff were encouraged to see themselves as teachers of all students through participating in continued agency IPE experiences, including becoming a preceptor. Site-specific precepting manuals and orientation videos were created for all clinical staff to discuss benefits and challenges of interprofessional precepting. CECs and IPE preceptors conducted biweekly or monthly case-based interprofessional meetings with students, guided student IPE projects, and collaborated with clinical staff to promote interprofessional mental health care. Faculty continue to support the agency CECs in monthly video conference meetings to discuss teaching ideas and challenges, IPE resources, participating as guest discussion leader at student IPE meetings, and providing ongoing mentorship to new CECs as they replace previous CECs.

Recommendations

Our IPE curricular changes have been sustained for 5 years. Based on our work together over 6 years, we have recommendations for faculty who are about to embark on their own journey toward graduate health profession interprofessional education.

Prepare Faculty and Clinical Organizations for an Interprofessional Education and Practice Environment

Faculty members from the SON and COP programs had a shared vision for IPE and were committed to working together to meet the aim of the HRSA grant to create IPE activities. However, we had our own professional disciplinary perspectives and struggled in the beginning with how to teach from a joint and interprofessional perspective. Early participation in interprofessional workshops and conferences to gain confidence in teaching IPE was important, as was our own personal assessment of IPE readiness. We reviewed and discussed the IPE for collaborative practice literature to identify strategies for sustainable IPE experiences. We learned that successful interprofessional teaching partnerships do not happen automatically, but require intentional, regular, and frequent meetings to assess progress as an interprofessional teaching team and to trust each other's knowledge and skill as an interprofessional teacher and health care provider. Preparation of the clinical site for IPE and practice was critical. Using an organizational readiness tool like InSITE provided plenty of opportunities for discussion about clinical teaching of IPE and strategies to create optimal interprofessional clinical learning environments.

Plan for the Time, Money, Motivation, and Recognition That Collaborative Teaching Demands

For curricular changes to be sustainable, faculty need the time to create, implement, and evaluate the learning progress of the students. Trying to arrange time to meet together with busy schedules was challenging, even with access to common calendars. We met regularly for 6 to 12 months prior to making curriculum changes for planning and problem solving, and reported our progress in the monthly HRSA leadership meetings. Our added faculty workload was supported by HRSA funding. Without this type of funding, universities and schools rely on IPE champions to incorporate emerging IPE models such as that featured in this article. Faculty collaborated to disseminate this work through publications and presentations at national and international conferences. It was important for faculty to be recognized for these creative, sustaining curricular changes so faculty were encouraged by administration to highlight the IPE accomplishments in their annual faculty evaluations and merit reviews. Our scholarship activities continue to support academic and professional growth and provide peer review, evaluation, and recognition of our IPE collaborative work.

Design Courses That Become Part of the Fabric of the Health Professional Curricula, Not as Add-Ons That Can Drop Off When Funding Disappears

For the first 2 years of the DNP PMHNP IPE courses, PharmD students registered for the nursing-designated courses and the SON received 75% of all student course tuition (COP received 25%) because the SON developed the course content and was primarily responsible for teaching the course. Once stability was reached in the course design and the COP decided to continue this joint learning experience, the COP created its own course designator. From the third year forward, PharmD students registered for the two courses using a pharmacy course designator number. This change meant that the COP received 75% of student course tuition (SON received 25%) and funds were then budgeted by the COP for PharmD faculty to teach in courses. The courses were approved by both faculties, and course content has remained consistent. Consistency in the course structure and content has allowed different SON and COP faculty to join the faculty teaching team with greater ease. Simulation costs were paid for by the HRSA grant and will continue to be shared by the SON and COP when grant funding ends.

Prepare Clinical Staff for the Role of an Interprofessional Preceptor

Our faculty team worked with clinical education coordinators and clinical staff to prepare for their role of IP preceptor. Clinical staff were initially concerned about teaching and supervising and precepting students outside of their own discipline, so we offered in-services, modeled IPEC concepts during student meetings, and created agency-specific IPE precepting manuals and student learning experiences. The use of IP language became more comfortable, and clinical staff began to gain confidence that they had something to offer when teaching students across disciplines.

Conclusion

Although the IPE curricular changes and collaboration between the SON and COP described were initially developed with support from HRSA funding, the initiative is in its sixth year of operation. The initiative has course and clinical IPE activities formalized within each program to ensure sustainability regardless of course faculty and clinical site staff. We have also identified sustained benefits such as faculty satisfaction, positive feedback from students, and positive responses from clinical sites. Future reports will detail the evaluation data collected over the 6-year period of this initiative.

IPE development and implementation is challenging for many complex reasons—many IPE initiatives do not persist following the initial project conclusion and/or changes in faculty leads. The purpose of this article is to provide a development and process example that successfully addressed the well-documented challenges to implementing sustained IPE curricular change and provide IPE curriculum development and implementation recommendations for faculty to transfer to their own institutional contexts.

References

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Authors

Dr. Peterson is Clinical Associate Professor, Dr. Kaas is Professor, University of Minnesota School of Nursing, Dr. Pittenger is Associate Professor, and Dr. Lounsbery is Associate Professor, University of Minnesota College of Pharmacy, Minneapolis, Minnesota.

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

Address correspondence to Barbara L. Peterson, PhD, PMHCNS-BC, Clinical Associate Professor, University of Minnesota School of Nursing, 6-188 Weaver Densford Hall, Minneapolis, MN 55455; e-mail: Pete1389@umn.edu.

Received: December 31, 2018
Accepted: August 21, 2019

10.3928/01484834-20191120-08

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