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Feature Article Integrating Geropsychiatric Nursing and Interprofessional Collaborative Practice Competencies Into Adult-Gerontology Clinical Nurse Specialist Education Ann M. Mayo, DNSc, RN, CNS, FAAN n Melodee Harris, PhD, APRN, GNP-BC n Bill Buron, PhD, APRN, GNP/FNP-BC
Specific changes to the national clinical nurse specialist (CNS) certification are necessitating a move away the psychiatric/mental health (P/MH) CNS population focus. However, a rapidly increasing older adult population with P/MH comorbidities such as depression and anxiety means that the adult-gerontology CNS (AGCNS) will likely be coordinating much of the complex care needs of this vulnerable population. Therefore, strategies are needed to ensure AGCNSs are competent in advanced practice P/MH nursing. In addition, at this critical time in the redesign of healthcare, the Institute of Medicine has made interprofessional practice center stage for healthcare professional education. Therefore, the purpose of this manuscript is to propose aligning the current AGCNS population-focused competencies with the CNS geropsychiatric nursing competency enhancements and interprofessional collaborative practice education competencies. Examples of the proposed alignment and educational application strategies are presented. When AGCNS educational curricula encompass P/MH nursing at an advanced level from an interprofessional perspective, future AGCNSs will continue to be positioned to make significant contributions to the design of care systems and monitor and trend important outcomes, while ensuring safe and efficient, high-quality healthcare for older adults with P/MH comorbidities. Author Affiliations: Professor, Hahn School of Nursing & Health Science, University of San Diego, California (Dr Mayo); Clinical Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock (Dr Harris); and Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Fayetteville (Dr Buron). The authors report no conflicts of interest. Correspondence: Ann M. Mayo, DNSc, RN, CNS, FAAN, Hahn School of Nursing & Health Science and Beyster Institute for Nursing Research, University of San Diego, 5998 Alcala Park, San Diego, CA 92110 (annmrn@ aol.com; [email protected]). DOI: 10.1097/NUR.0000000000000248
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KEY WORDS: adult-gerontology CNS, clinical nurse specialist education, CNS geropsychiatric nursing competency enhancements, interprofessional collaborative practice education competencies, psychiatric/mental health
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number of contemporary social, professional, and pedagogical trends are simultaneously converging and transforming healthcare education and delivery in the United States. An aging society with significant mental health needs, a lack of educational programs resulting in a dearth of geropsychiatric healthcare professionals, and the imposing vision of the Institute of Medicine1 to provide collaborative team-based patient care are all important factors affecting clinical nurse specialist (CNS) education. In addition, specific changes to national certification are affecting CNS education in the area of advanced practice psychiatric/mental health (P/MH), moving it out of a population focus and into a specialty. Motivating alternatives are needed to ensure CNSs are adequately prepared for advanced practice P/MH, especially as applied to the vulnerable aging population. The complex nature of older adult care delivery today demands a higher level of expertise in geropsychiatric nursing (GPN), as well as proficiency in team-based care that was not emphasized in the past. Therefore, CNS faculty teaching in adult-gerontology CNS (AGCNS) programs are now challenged to incorporate these foci into their curricula, and this can be a challenge. Two critical sets of competencies for AGCNS programs include the CNS geropsychiatric nursing competency enhancements (GPNCEs)2 and the interprofessional collaborative practice education competencies (ICPEC).3 The primary aims of this manuscript are
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to (1) describe the CNS GPNCEs2 and ICPEC,3 (2) propose aligning the GPNCEs and ICPEC with the AGCNS populationfocused competencies,4 and (3) provide application examples of the complementary competencies to prepare the next generation of AGCNSs with competence in GPN and interprofessional practice.
THE IMPETUS FOR CHANGE IN CNS EDUCATION The US Census Bureau reports that the population of older people is expected to grow from 40.2 million in 2010 to 88.5 million in 2050. Seventy-five percent of older adults (65 years or older) report excellent physical health, meaning that many older people with mental illness are likely living longer.5 Equally important, physical illness among older adults often precipitates or accompanies psychiatric symptoms, thereby adding to the burden of providing care for older adults. There are approximately 7 million older people with P/MH conditions such as delirium, depression, bipolar disorders, and substance misuse living in the United States.6 No matter the reason for escalating P/MH illnesses, it is imperative that all nurses caring for older adults be prepared in all aspects of GPN.7 However, with nursing curricula already impacted with content at the undergraduate level, there will be a need for AGCNSs to lead and mentor nursing staff in the delivery of high-quality, safe patient care targeting this vulnerable hospitalized population. Historically, the first geropsychiatric nurses were CNSs.8 Therefore, the CNS and, most likely, the AGCNS will be stepping up to lead nurses in the care of these older adult patients with primary and comorbid P/MH illnesses. Schools of nursing with AGCNS programs are therefore challenged to incorporate P/MH content into their already full graduate curricula. Comprehensive education of AGCNS students in GPN and interprofessional practice is important. In the practice setting, planning for the care of older adults with geropsychiatric diagnoses and comorbidities is complex, requiring coordinated input from a number of disciplines including nursing, medicine, psychiatry, psychology, social work, and pharmacy. Therefore, GPN practice and interprofessional practice are critically important when care is provided to older adults.9 As early as 1972, the Institute of Medicine (IOM)10 has strongly recommended that all healthcare providers be educated to collaborate to provide quality care. Decades later, after limited progress toward this goal, the IOM charged the newly formed Interprofessional Education Collaborative (IPEC) Expert Panel to publish ‘‘collaborating’’ competencies for all healthcare providers.3 Two years later, in 2012, the IOM published The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?11 This report recognized the overwhelming need for a healthcare workforce that is prepared and competent to meet the needs of older adults with P/MH conditions. Our work presented Clinical Nurse Specialist
here takes 2 important IOM coordinated efforts (interprofessional education and preparation in GPN) and lays out a plan for combining these recommendations to move AGCNS education toward that goal.
THE MAZE OF CNS COMPETENCIES A competency-based nursing education program integrates professional nursing values within a curriculum that is outcome focused with an emphasis on evidence-based practice (EBP).12 Numerous competencies are recommended for APRN education. Beginning with basic competencies, separate CNS core competencies are available for MSN13 and DNP14 programs. Combining forces, the Advanced Practice Registered Nurse (APRN) Consensus Model Work Group, the APRN Advisory Committee of the National Council of State Boards of Nursing, and representative nursing organizations identified 6 original population foci (ie, adult-gerontology, neonatal, and pediatric) for APRNs.15 Since the identification of these population foci, the National Association of Clinical Nurse Specialist, American Association of Colleges of Nursing, and other professional APRN organizations have been collaborating to develop role-specific (eg, CNS, nurse practitioner) sets of APRN competencies that address the specific populations.4,16 Not specified by MSN or DNP degree, each set of CNS population foci competencies is organized across the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy and cross-referenced to the dominant practice framework of the CNS spheres of influence (patient/client, nurses/nursing, and system/organizational). The AGCNS population-focused set of competencies is available to schools of nursing.4 Competencies are matched to the 3 CNS spheres of influence for straightforward incorporation into AGCNS program documents. Graduate faculty teaching in adult health and/or geriatric-focused CNS programs are now transitioning those programs into new AGCNS programs. Those teaching in newer AGCNS programs will need to incorporate these recommended AGCNS population-focused competencies. Although these contain numerous important adult-gerontology competencies, they do not fully address 2 important needs for AGCNS students: GPN education and interprofessional education. GPN EDUCATION Geropsychiatric nursing is formally defined as ‘‘holistic support for and care of older adults and their families as they participate and/or experience developmental challenges, mental health concerns and psychiatric/substance misuse disorders across a variety of health and mental health settings.’’17(para1) Although well defined as a practice, the design, implementation, and promotion of GPN APRN education had historically been problematic for
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Feature Article graduate programs in schools of nursing because there has never been a nationally recognized certification program in GPN for advanced practice nurses.18 A strategic approach to promoting GPN education in 2008 included the formation of the Geropsychiatric Nursing Collaboration (GPNC). The GPNC goal was to enhance the knowledge and skills of nurses to improve the quality of mental healthcare provided to older adults.7 The GPNC’s objectives were to review, create, and disseminate undergraduate and graduate core GPNCEs to every school of nursing in the country.7 The competency enhancements were founded on 27 key concepts across 4 domains: assessment, management, approach to older adults, and role. Overall, the 27 key concepts could be threaded throughout most nursing curricula. Drafted in 2008, 3 sets of role-specific GPNCEs were developed by the GPNC for use in CNS education. To facilitate use, the CNS GPNCEs were also organized across the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy. Because this work predated the implementation phase of the APRN Consensus Model, these sets of CNS GPN enhancements were originally developed for CNS nursing students enrolled in (1) geriatric CNS programs (geriatric national certificate examination now being retired), (2) P/MH CNS programs (CNS national certificate examination now being retired), and (3) other ‘‘CNSs who were not in geriatric specialists’ specialty’’ CNS programs.2 Across the United States, CNS programs are now being designed around the new APRN population foci, so we are recommending using the ‘‘CNSs who are not geriatric specialists’’ version of GPNCEs for the new AGCNS programs. These GPNCEs best compliment the new core APRN practice competencies for the AGCNS because they address both adult and geriatric populations. In addition, they will also enhance CNS specialties such as cardiovascular, diabetes, and oncology that may be taught as specialties within new AGCNS programs. For a sample of the recommended GPNCEs, see Table 1.
INTERPROFESSIONAL COLLABORATIVE PRACTICE EDUCATION Well known by practicing CNSs and CNS faculty, emerging patient safety issues have revealed a serious lack of communication and collaboration among healthcare disciplines. As a result, 4 interprofessional collaborative practice domains with accompanying competencies were developed by the IPEC Expert Panel and endorsed by many healthcare disciplines.3 Nursing and other disciplines have been challenged to incorporate these competencies into curricula as rapidly as possible. Ideally, this would be accomplished collaboratively among healthcare disciplines. However, these competencies must have prominence within nursing curricula, including CNS education. 326
Interprofessional Collaborative Practice Domains The interprofessional collaborative practice domains include (1) values and ethics, (2) roles and responsibilities, (3) interprofessional communication, and (4) teams and teamwork3 (see Table 2). All are important competency domains. Because the competencies are intercollaborative, they support CNS practice, as well as other healthcare professionals’ practice, to focus the delivery of patient care in a collaborative way. Patient safety is improved when team members understand their unique and overlapping roles and members of the team communicate in an effective manner. As an example, an interdisciplinary communication tool, situation-background-assessment-recommendation, has resulted in significant improvements in betweengroup communication accuracy and safety climate, as well as significant reductions in incident reports due to communication errors.19 Collaborative work is also important for EBP projects. In fact, the Trans-disciplinary Model of EBP and Health Professionals’ Roles in EBP have been developed to support interdisciplinary EBP work and the translation of evidence across different disciplines.20 Converging AGCNS GPNCEs and ICPEC Nursing faculty have a critical role to play in implementing CNS GPNCEs and interprofessional collaborative practice competencies into AGCNS education. We recommend a novel approach to preparing AGCNS students to care for the escalating complex aging population, many of whom have co-occurring P/MH illnesses. The 3 sets of competencies can be converged based upon commonalities. Examples of complementary competencies are provided in Table 3. Faculty Knowledge Enhancement As a first step, nursing faculty should obtain a working knowledge of the AGCNS GPN competency enhancement content for the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy; the CNS geropsychiatric competencies; and the interprofessional collaborative practice domain competencies. Our recommendations include the geropsychiatric enhancements for ‘‘clinical nurse specialists who provide care to older adults but are not geriatric specialists,’’2 AGCNS competencies,4 and the IPEC core competencies.3 In addition, faculty can increase their knowledge of interprofessional collaboration through the many resources found on the IPEC Web site (https://ipecollaborative.org/).21 The University of Minnesota houses the National Center for Interprofessional Practice and Education.22 Their Web site (https://nexusipe.org) covers an invaluable supply of resources for additional faculty development in interprofessional education.
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Table 1. Sample of CNS Geropsychiatric Competency Enhancements for CNSs Who Provide Care to Older Adults but Are Not Geriatric Specialistsa Competency Categories
Sample Competencies
A. Direct care competency
Identifies and assesses factors that affect mental health including stressors that may be more common among older adults such as caregiving, multiple chronic illnesses, pain, relocation, trauma, cohort-specific stressors and losses such as financial (retirement), functional limitations (instrumental activities of daily living/activities of daily living), changes in social network (death of family members and friends), and role (status changes). Uses behavioral, environmental, and pharmacological management strategies to ameliorate behavioral symptoms in individuals who have psychiatric/substance misuse disorders, including cognitive impairments.
B. Consultation competency
GPNC had no geropsychiatric competency enhancements to recommend beyond the adult-gerontology CNS population-focused competencies.
C. Systems leadership competency
Participates in quality improvement initiatives designed to improve care for older adults with mental illness and cognitive impairment. Coordinates transitions across levels of care between acute care and community-based long-term care settings (eg, home, assisted living, hospice, nursing homes) for older adults and their families.
D. Collaboration competency
Demonstrates knowledge of the similarities and differences in roles of the various healthcare professionals.
E. Coaching competency
Analyzes the impact of aging and age- and disease-related changes in sensory/perceptual function, cognition, confidence with technology, and health literacy and numeracy on the ability and readiness to learn and tailors interventions accordingly. Assists older adults, caregivers, and their families to negotiate healthcare delivery systems, including mental health services.
F. Research competency
GPNC had no geropsychiatric competency enhancements to recommend beyond the adult-gerontology CNS population-focused competencies.
G. Ethical decision making, moral agency, and advocacy
Applies knowledge of issues related to decisional capacity (including the balance between autonomy and safety), guardianship, financial management, and durable and healthcare powers of attorney to the treatment for older adults. Advocates for the behavioral and mental health needs of older adults.
2
Source: Beck et al. Abbreviations: CNS(s), clinical nurse specialist(s); GPNC, Geropsychiatric Nursing Collaboration. a The APRN national certification in the specialty of geriatrics is no longer available; therefore, this version of geropsychiatric competency enhancements is presented.
Current Program Gap Analysis With a working understanding of the different sets of competencies, the next step should be to conduct an in-depth review of the CNS program in the current AGCNS nursing curriculum for the presence of the 3 sets of competencies. If the faculty has explicitly included competencies in their syllabi, this process can easily be accomplished. However, competencies may be located in other course documents as well (ie, in a skills checklist). Otherwise, additional steps may be required of individual faculty to document the extent that any of the competencies are currently addressed in their courses. Where gaps are found, integrated strategies to advance AGCNS student competency-based knowledge will be needed. Complementary Competency Matrix A matrix crosswalk of the AGCNS competencies to both the CNS GPNCEs and interprofessional collaborative practice Clinical Nurse Specialist
competencies can be used to identify complementary competencies that may be addressed using multiple teaching strategies. See Table 3 for an example of a complementary competency matrix. In this example, we have identified competencies that we feel are complementary. The faculty is encouraged to collectively examine all 3 sets of competencies to identify complementary themes, as we have done here. Beginning with the patient sphere (also termed direct care), the AGCNS competency addressing assessment can be paired with the CNS GPNCE that also addresses assessment. As can be seen in Table 3, the CNS GPNCE is more specific regarding mental health and stress assessment. The interprofessional collaborative practice competency focused on the domain of interprofessional teamwork and team-based care adds yet another dimension to the CNS assessment function. Here, the knowledge and experience of the entire team come together to focus on patient-centered problem solvingVthe ultimate outcome of any patient
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Feature Article Table 2. Interprofessional Collaborative Practice Competency Domains and Specific Competency Examples Competency domain 1: values/ethics VE2. Respect the dignity and privacy of patients while maintaining confidentiality in the delivery of team-based care. VE10. Maintain competence in one"s own profession appropriate to the scope of practice. Competency domain 2: roles/responsibilities for collaborative practice RR1. Communicate one"s roles and responsibilities clearly to patients, families, and other professionals. RR5. Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable. Competency domain 3: interprofessional communication CC1. Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function. CC5. Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. Competency domain 4: interprofessional teamwork and team-based care TT3. Engage other health professionalsVappropriate to the specific care situationVin shared patient-centered problem solving. TT4. Integrate the knowledge and experience of other professionsVappropriate to the specific care situationVto inform care decisions, while respecting patient and community values and priorities/preferences for care. Source: American Association of Colleges of Nursing et al3 (2011).
assessment. In this example, the AGCNS competency provides a general view of the CNS assessment. The CNS GPNCE enhances the assessment. Finally, the interprofessional competency helps to focus the assessment in the direction of a measureable outcome, underpinned by the entire team’s assessment (knowledge and experience of other professions). Other sets of competencies are complementary in other ways. For example, one of the nurse sphere/coaching AGCNS competencies already is team focused (eg, assists healthcare team members to integrate the needs, preferences, and strengths of the patient into the healthcare plan to optimize health outcomes). The CNS GPNCE that is related to this competency is that he/she needs an understanding of the different team members’ roles. Finally, one of the communication-focused interprofessional competencies can be used to highlight the importance of the CNS (and other team members), maintaining continuous quality by providing instructive feedback to team members. In essence, the interprofessional competency moves the nurse sphere to a team sphere function for the AGCNS. As is commonly known, aging older adults with chronic illnesses are complex and best managed from a team perspective,23Y25 and so these 3 competencies reinforce that important concept. As can also be seen in Table 3, there is a quality and safety focus across all 3 samples of competencies. The AGCNS student should have numerous opportunities to observe CNS leadership in the area of quality and safety because CNS preceptors frequently chair nursing quality and patient safety committees. The goal in highlighting 328
interprofessional participation and leadership would be to encourage AGCNS students to attend system-level quality and patient safety committee meetings where directors of quality and risk management departments, along with medical doctors (MDs) and other healthcare professionals, are presenting and discussing issues that impact the organization’s accreditation and licensing. Learning activities can be designed to incorporate the features of all 3 sets of competencies. For example, a CNS patient sphere interprofessional case study or a simulation exercise addressing assessment; care planning; nurse, MD, and pharmacy activities; and outcomes reporting through a communication mechanism could be designed for older adults experiencing depression. The development of a CNS nurse sphere teaching plan for staff nurses and social workers could be assigned on the topic of assessing anxiety and substance misuse among older adults. Finally, a CNS organizational sphere capstone project could address the implementation, monitoring, and indicator outcomes for an evidence-based delirium prevention program for older adults. Such a project would emphasize the identification of key stakeholders in the early phase so that the CNS student could incorporate an interprofessional focus to the entire project including the design, implementation, and evaluation phases.
INFRASTRUCTURE TO ADVANCE AGCNS STUDENT KNOWLEDGE AND SKILLS Innovation in education strategies integrating GPN must be directed toward collaborative courses taught by faculty
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Table 3. Sample Complementary Competency Matrix Linking Adult-Gerontology CNS Competencies to CNS Geropsychiatric Competency Enhancements and Interprofessional Collaborative Practice Education Competencies Adult-Gerontology CNS PopulationFocused Competencies4
CNS Geropsychiatric Competency Enhancements2
Interprofessional Collaborative Practice Education Competencies3
Patient sphere/direct care competency
Direct care
Values/ethics
Conducts a comprehensive, holistic assessment of individuals including those who are nonverbally, developmentally, functionally, and/or cognitively impaired (A-1).
Identifies and assesses factors that affect mental health including stressors that may be more common among older adults such as caregiving, multiple chronic illnesses, pain, relocation, trauma, cohort-specific stressors and losses such as financial (retirement), functional limitations (instrumental activities of daily living/activities of daily living), changes in social network (death of family members and friends), and role (status changes) (A).
Maintain competence in one"s own profession appropriate to the scope of practice (V10).
Nurse sphere/coaching competency
Collaboration competency
Interprofessional communication
Assists healthcare team members to integrate the needs, preferences, and strengths of the patient into the healthcare plan to optimize health outcomes (B-1).
Demonstrates knowledge of the similarities and differences in roles of the various healthcare professionals (D).
Give timely, sensitive, instructive feedback to others about their performance on the team and respond respectively as a team member to feedback from others (CC5).
Interprofessional teamwork and team-based care Integrate the knowledge and experience of other professionsVappropriate to the specific care situationVin shared patient-centered problem solving (TT4).
Systems/organizational sphere
Systems leadership competency
Roles/responsibilities for collaborative practice
Provides leadership to address threats to healthcare safety and quality in the adultYolder adult populations (C-4).
Participates in quality improvement initiatives designed to improve care for older adults with mental illness and cognitive impairment (C).
Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide safe, timely, efficient, effective, and equitable care (RR5).
Abbreviation: CNS, clinical nurse specialist.
from all the health sciences, including interprofessional simulation experiences and clinical practice such as rounding with all disciplines. Achieving this goal will first require partnerships among deans representing health sciences schools within and between universities. Where barriers are encountered, expert consultants in interprofessional education may need to play a role in making recommendations for such education to convince key stakeholders. Consultancy models to promote interprofessional collaboration have been effective in healthcare organizations26 and may also be effective in academic settings. Second, because change can be disruptive and therefore be resisted by some faculty, we recommend a faculty person be designated to champion the implementation of the additional competencies into the curriculum. Using healthcare administrators as champions, including implementing interdisciplinary practice in a clinical setting, has been successful.27 Such champions influence the structure and culture within organizations so that interprofessional practice change happens. In fact, Begun et al27 have identified 17 administrator competencies for the support of interdisciplinary practice. One example of an administrator competency includes strengthening collaborating connecClinical Nurse Specialist
tions among the professions of nursing, medicine, and pharmacy. This has been accomplished by supporting collaborative work on clinically based projects and encouraging the professionals to be guest speakers in each other’s departments. A second example includes developing organization-wide interprofessional culture. The goal here is to lead the incorporation of the organization’s ‘‘vision, values, symbols, norms, stories, ceremonies, and rituals’’ into an interprofessional mission.27(p121) Similar champions may be equally successful in universities. Finally, although many CNSs are employed in hospital settings, it is important to expand clinical settings beyond the hospital to include community, clinic, assisted living, and nursing home settings. From both a geropsychiatric content and interprofessional culture perspective, professional roles can differ based upon the setting.28 For example, whereas the CNS may lead the team in the hospital setting, a nurse practitioner or MD may take the lead in the clinic setting. Practice in multiple settings will allow the AGCNS student to experience leadership, as well as supportive roles, when caring for older adults with complex P/MH illnesses. In the long term, practice outside the hospital setting will allow AGCNS students and their faculty to
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Feature Article contribute to improving the quality of transitions from 1 setting to another, a critical need for older adults experiencing P/MH illnesses.
ONGOING PROGRAM DEVELOPMENT Whether concerns are with patient, nursing, system, or academic improvements, sustaining gains and advancing programs can be problematic. We offer a number of suggestions for faculty who implement the recommended competencies such as joining key professional organizations and special interest groups and regularly attending conferences. Schools of nursing’s AGCNS faculty can take advantage of joining and playing a prominent role in interprofessional organizations such as the American Geriatrics Society and the Gerontological Society of America. Attending these organizations’ conferences will keep AGCNS faculties up to date with the latest geropsychiatric evidence. Interprofessional special interest groups exist within each of these organizations, and these are quite helpful for networking around certain topics such as Alzheimer’s disease, ageism, and ethical dilemmas. Of special interest is that there is a growing cadre of gerontological nursing leaders within the Gerontological Society of America who make up the membership of the GPNC Work Group. The focus of this work group is to improve GPN care from an interprofessional perspective through education, practice, and research.29 Collaborative working GPNC sessions are scheduled annually to include interprofessional geriatric and gerontological faculty, clinicians, and researchers. Participation in this group will ensure that AGCNS faculties are up to date on the latest GPN nursing, social work, medical, and interprofessional evidence, while also allowing for a dialog about the latest pedagogy and providing opportunities for research and publishing. Such experiences infuse GPN education with fresh ideas so that faculties returning to their campuses sustain gains made in previous years and advance their AGCNS programs in terms of GPN. CONCLUSIONS Geropsychiatric nursing and interprofessional practice is essential for the care of older adults with P/MH illnesses across all settings. Teams of providers have the advantage of combining their expertise to make the best practice decisions. Additional competencies for GPN and interprofessional education can be combined with AGCNS competencies to ensure a competent CNS workforce. These AGCNSs will be better prepared to work on interprofessional teams and thereby meet the needs of the growing population of older adults with P/MH illnesses, ensuring the delivery of safe patient care and excellent patient outcomes. 330
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Feature Article Integrating Geropsychiatric Nursing and Interprofessional Collaborative Practice Competencies Into Adult-Gerontology Clinical Nurse Specialist Education Ann M. Mayo, DNSc, RN, CNS, FAAN n Melodee Harris, PhD, APRN, GNP-BC n Bill Buron, PhD, APRN, GNP/FNP-BC
Specific changes to the national clinical nurse specialist (CNS) certification are necessitating a move away the psychiatric/mental health (P/MH) CNS population focus. However, a rapidly increasing older adult population with P/MH comorbidities such as depression and anxiety means that the adult-gerontology CNS (AGCNS) will likely be coordinating much of the complex care needs of this vulnerable population. Therefore, strategies are needed to ensure AGCNSs are competent in advanced practice P/MH nursing. In addition, at this critical time in the redesign of healthcare, the Institute of Medicine has made interprofessional practice center stage for healthcare professional education. Therefore, the purpose of this manuscript is to propose aligning the current AGCNS population-focused competencies with the CNS geropsychiatric nursing competency enhancements and interprofessional collaborative practice education competencies. Examples of the proposed alignment and educational application strategies are presented. When AGCNS educational curricula encompass P/MH nursing at an advanced level from an interprofessional perspective, future AGCNSs will continue to be positioned to make significant contributions to the design of care systems and monitor and trend important outcomes, while ensuring safe and efficient, high-quality healthcare for older adults with P/MH comorbidities. Author Affiliations: Professor, Hahn School of Nursing & Health Science, University of San Diego, California (Dr Mayo); Clinical Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Little Rock (Dr Harris); and Assistant Professor, College of Nursing, University of Arkansas for Medical Sciences, Fayetteville (Dr Buron). The authors report no conflicts of interest. Correspondence: Ann M. Mayo, DNSc, RN, CNS, FAAN, Hahn School of Nursing & Health Science and Beyster Institute for Nursing Research, University of San Diego, 5998 Alcala Park, San Diego, CA 92110 (annmrn@ aol.com; [email protected]). DOI: 10.1097/NUR.0000000000000248
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KEY WORDS: adult-gerontology CNS, clinical nurse specialist education, CNS geropsychiatric nursing competency enhancements, interprofessional collaborative practice education competencies, psychiatric/mental health
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number of contemporary social, professional, and pedagogical trends are simultaneously converging and transforming healthcare education and delivery in the United States. An aging society with significant mental health needs, a lack of educational programs resulting in a dearth of geropsychiatric healthcare professionals, and the imposing vision of the Institute of Medicine1 to provide collaborative team-based patient care are all important factors affecting clinical nurse specialist (CNS) education. In addition, specific changes to national certification are affecting CNS education in the area of advanced practice psychiatric/mental health (P/MH), moving it out of a population focus and into a specialty. Motivating alternatives are needed to ensure CNSs are adequately prepared for advanced practice P/MH, especially as applied to the vulnerable aging population. The complex nature of older adult care delivery today demands a higher level of expertise in geropsychiatric nursing (GPN), as well as proficiency in team-based care that was not emphasized in the past. Therefore, CNS faculty teaching in adult-gerontology CNS (AGCNS) programs are now challenged to incorporate these foci into their curricula, and this can be a challenge. Two critical sets of competencies for AGCNS programs include the CNS geropsychiatric nursing competency enhancements (GPNCEs)2 and the interprofessional collaborative practice education competencies (ICPEC).3 The primary aims of this manuscript are
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to (1) describe the CNS GPNCEs2 and ICPEC,3 (2) propose aligning the GPNCEs and ICPEC with the AGCNS populationfocused competencies,4 and (3) provide application examples of the complementary competencies to prepare the next generation of AGCNSs with competence in GPN and interprofessional practice.
THE IMPETUS FOR CHANGE IN CNS EDUCATION The US Census Bureau reports that the population of older people is expected to grow from 40.2 million in 2010 to 88.5 million in 2050. Seventy-five percent of older adults (65 years or older) report excellent physical health, meaning that many older people with mental illness are likely living longer.5 Equally important, physical illness among older adults often precipitates or accompanies psychiatric symptoms, thereby adding to the burden of providing care for older adults. There are approximately 7 million older people with P/MH conditions such as delirium, depression, bipolar disorders, and substance misuse living in the United States.6 No matter the reason for escalating P/MH illnesses, it is imperative that all nurses caring for older adults be prepared in all aspects of GPN.7 However, with nursing curricula already impacted with content at the undergraduate level, there will be a need for AGCNSs to lead and mentor nursing staff in the delivery of high-quality, safe patient care targeting this vulnerable hospitalized population. Historically, the first geropsychiatric nurses were CNSs.8 Therefore, the CNS and, most likely, the AGCNS will be stepping up to lead nurses in the care of these older adult patients with primary and comorbid P/MH illnesses. Schools of nursing with AGCNS programs are therefore challenged to incorporate P/MH content into their already full graduate curricula. Comprehensive education of AGCNS students in GPN and interprofessional practice is important. In the practice setting, planning for the care of older adults with geropsychiatric diagnoses and comorbidities is complex, requiring coordinated input from a number of disciplines including nursing, medicine, psychiatry, psychology, social work, and pharmacy. Therefore, GPN practice and interprofessional practice are critically important when care is provided to older adults.9 As early as 1972, the Institute of Medicine (IOM)10 has strongly recommended that all healthcare providers be educated to collaborate to provide quality care. Decades later, after limited progress toward this goal, the IOM charged the newly formed Interprofessional Education Collaborative (IPEC) Expert Panel to publish ‘‘collaborating’’ competencies for all healthcare providers.3 Two years later, in 2012, the IOM published The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?11 This report recognized the overwhelming need for a healthcare workforce that is prepared and competent to meet the needs of older adults with P/MH conditions. Our work presented Clinical Nurse Specialist
here takes 2 important IOM coordinated efforts (interprofessional education and preparation in GPN) and lays out a plan for combining these recommendations to move AGCNS education toward that goal.
THE MAZE OF CNS COMPETENCIES A competency-based nursing education program integrates professional nursing values within a curriculum that is outcome focused with an emphasis on evidence-based practice (EBP).12 Numerous competencies are recommended for APRN education. Beginning with basic competencies, separate CNS core competencies are available for MSN13 and DNP14 programs. Combining forces, the Advanced Practice Registered Nurse (APRN) Consensus Model Work Group, the APRN Advisory Committee of the National Council of State Boards of Nursing, and representative nursing organizations identified 6 original population foci (ie, adult-gerontology, neonatal, and pediatric) for APRNs.15 Since the identification of these population foci, the National Association of Clinical Nurse Specialist, American Association of Colleges of Nursing, and other professional APRN organizations have been collaborating to develop role-specific (eg, CNS, nurse practitioner) sets of APRN competencies that address the specific populations.4,16 Not specified by MSN or DNP degree, each set of CNS population foci competencies is organized across the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy and cross-referenced to the dominant practice framework of the CNS spheres of influence (patient/client, nurses/nursing, and system/organizational). The AGCNS population-focused set of competencies is available to schools of nursing.4 Competencies are matched to the 3 CNS spheres of influence for straightforward incorporation into AGCNS program documents. Graduate faculty teaching in adult health and/or geriatric-focused CNS programs are now transitioning those programs into new AGCNS programs. Those teaching in newer AGCNS programs will need to incorporate these recommended AGCNS population-focused competencies. Although these contain numerous important adult-gerontology competencies, they do not fully address 2 important needs for AGCNS students: GPN education and interprofessional education. GPN EDUCATION Geropsychiatric nursing is formally defined as ‘‘holistic support for and care of older adults and their families as they participate and/or experience developmental challenges, mental health concerns and psychiatric/substance misuse disorders across a variety of health and mental health settings.’’17(para1) Although well defined as a practice, the design, implementation, and promotion of GPN APRN education had historically been problematic for
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Feature Article graduate programs in schools of nursing because there has never been a nationally recognized certification program in GPN for advanced practice nurses.18 A strategic approach to promoting GPN education in 2008 included the formation of the Geropsychiatric Nursing Collaboration (GPNC). The GPNC goal was to enhance the knowledge and skills of nurses to improve the quality of mental healthcare provided to older adults.7 The GPNC’s objectives were to review, create, and disseminate undergraduate and graduate core GPNCEs to every school of nursing in the country.7 The competency enhancements were founded on 27 key concepts across 4 domains: assessment, management, approach to older adults, and role. Overall, the 27 key concepts could be threaded throughout most nursing curricula. Drafted in 2008, 3 sets of role-specific GPNCEs were developed by the GPNC for use in CNS education. To facilitate use, the CNS GPNCEs were also organized across the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy. Because this work predated the implementation phase of the APRN Consensus Model, these sets of CNS GPN enhancements were originally developed for CNS nursing students enrolled in (1) geriatric CNS programs (geriatric national certificate examination now being retired), (2) P/MH CNS programs (CNS national certificate examination now being retired), and (3) other ‘‘CNSs who were not in geriatric specialists’ specialty’’ CNS programs.2 Across the United States, CNS programs are now being designed around the new APRN population foci, so we are recommending using the ‘‘CNSs who are not geriatric specialists’’ version of GPNCEs for the new AGCNS programs. These GPNCEs best compliment the new core APRN practice competencies for the AGCNS because they address both adult and geriatric populations. In addition, they will also enhance CNS specialties such as cardiovascular, diabetes, and oncology that may be taught as specialties within new AGCNS programs. For a sample of the recommended GPNCEs, see Table 1.
INTERPROFESSIONAL COLLABORATIVE PRACTICE EDUCATION Well known by practicing CNSs and CNS faculty, emerging patient safety issues have revealed a serious lack of communication and collaboration among healthcare disciplines. As a result, 4 interprofessional collaborative practice domains with accompanying competencies were developed by the IPEC Expert Panel and endorsed by many healthcare disciplines.3 Nursing and other disciplines have been challenged to incorporate these competencies into curricula as rapidly as possible. Ideally, this would be accomplished collaboratively among healthcare disciplines. However, these competencies must have prominence within nursing curricula, including CNS education. 326
Interprofessional Collaborative Practice Domains The interprofessional collaborative practice domains include (1) values and ethics, (2) roles and responsibilities, (3) interprofessional communication, and (4) teams and teamwork3 (see Table 2). All are important competency domains. Because the competencies are intercollaborative, they support CNS practice, as well as other healthcare professionals’ practice, to focus the delivery of patient care in a collaborative way. Patient safety is improved when team members understand their unique and overlapping roles and members of the team communicate in an effective manner. As an example, an interdisciplinary communication tool, situation-background-assessment-recommendation, has resulted in significant improvements in betweengroup communication accuracy and safety climate, as well as significant reductions in incident reports due to communication errors.19 Collaborative work is also important for EBP projects. In fact, the Trans-disciplinary Model of EBP and Health Professionals’ Roles in EBP have been developed to support interdisciplinary EBP work and the translation of evidence across different disciplines.20 Converging AGCNS GPNCEs and ICPEC Nursing faculty have a critical role to play in implementing CNS GPNCEs and interprofessional collaborative practice competencies into AGCNS education. We recommend a novel approach to preparing AGCNS students to care for the escalating complex aging population, many of whom have co-occurring P/MH illnesses. The 3 sets of competencies can be converged based upon commonalities. Examples of complementary competencies are provided in Table 3. Faculty Knowledge Enhancement As a first step, nursing faculty should obtain a working knowledge of the AGCNS GPN competency enhancement content for the domains of direct care, consultation, leadership, collaboration, coaching, research, ethical decision making, and advocacy; the CNS geropsychiatric competencies; and the interprofessional collaborative practice domain competencies. Our recommendations include the geropsychiatric enhancements for ‘‘clinical nurse specialists who provide care to older adults but are not geriatric specialists,’’2 AGCNS competencies,4 and the IPEC core competencies.3 In addition, faculty can increase their knowledge of interprofessional collaboration through the many resources found on the IPEC Web site (https://ipecollaborative.org/).21 The University of Minnesota houses the National Center for Interprofessional Practice and Education.22 Their Web site (https://nexusipe.org) covers an invaluable supply of resources for additional faculty development in interprofessional education.
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Table 1. Sample of CNS Geropsychiatric Competency Enhancements for CNSs Who Provide Care to Older Adults but Are Not Geriatric Specialistsa Competency Categories
Sample Competencies
A. Direct care competency
Identifies and assesses factors that affect mental health including stressors that may be more common among older adults such as caregiving, multiple chronic illnesses, pain, relocation, trauma, cohort-specific stressors and losses such as financial (retirement), functional limitations (instrumental activities of daily living/activities of daily living), changes in social network (death of family members and friends), and role (status changes). Uses behavioral, environmental, and pharmacological management strategies to ameliorate behavioral symptoms in individuals who have psychiatric/substance misuse disorders, including cognitive impairments.
B. Consultation competency
GPNC had no geropsychiatric competency enhancements to recommend beyond the adult-gerontology CNS population-focused competencies.
C. Systems leadership competency
Participates in quality improvement initiatives designed to improve care for older adults with mental illness and cognitive impairment. Coordinates transitions across levels of care between acute care and community-based long-term care settings (eg, home, assisted living, hospice, nursing homes) for older adults and their families.
D. Collaboration competency
Demonstrates knowledge of the similarities and differences in roles of the various healthcare professionals.
E. Coaching competency
Analyzes the impact of aging and age- and disease-related changes in sensory/perceptual function, cognition, confidence with technology, and health literacy and numeracy on the ability and readiness to learn and tailors interventions accordingly. Assists older adults, caregivers, and their families to negotiate healthcare delivery systems, including mental health services.
F. Research competency
GPNC had no geropsychiatric competency enhancements to recommend beyond the adult-gerontology CNS population-focused competencies.
G. Ethical decision making, moral agency, and advocacy
Applies knowledge of issues related to decisional capacity (including the balance between autonomy and safety), guardianship, financial management, and durable and healthcare powers of attorney to the treatment for older adults. Advocates for the behavioral and mental health needs of older adults.
2
Source: Beck et al. Abbreviations: CNS(s), clinical nurse specialist(s); GPNC, Geropsychiatric Nursing Collaboration. a The APRN national certification in the specialty of geriatrics is no longer available; therefore, this version of geropsychiatric competency enhancements is presented.
Current Program Gap Analysis With a working understanding of the different sets of competencies, the next step should be to conduct an in-depth review of the CNS program in the current AGCNS nursing curriculum for the presence of the 3 sets of competencies. If the faculty has explicitly included competencies in their syllabi, this process can easily be accomplished. However, competencies may be located in other course documents as well (ie, in a skills checklist). Otherwise, additional steps may be required of individual faculty to document the extent that any of the competencies are currently addressed in their courses. Where gaps are found, integrated strategies to advance AGCNS student competency-based knowledge will be needed. Complementary Competency Matrix A matrix crosswalk of the AGCNS competencies to both the CNS GPNCEs and interprofessional collaborative practice Clinical Nurse Specialist
competencies can be used to identify complementary competencies that may be addressed using multiple teaching strategies. See Table 3 for an example of a complementary competency matrix. In this example, we have identified competencies that we feel are complementary. The faculty is encouraged to collectively examine all 3 sets of competencies to identify complementary themes, as we have done here. Beginning with the patient sphere (also termed direct care), the AGCNS competency addressing assessment can be paired with the CNS GPNCE that also addresses assessment. As can be seen in Table 3, the CNS GPNCE is more specific regarding mental health and stress assessment. The interprofessional collaborative practice competency focused on the domain of interprofessional teamwork and team-based care adds yet another dimension to the CNS assessment function. Here, the knowledge and experience of the entire team come together to focus on patient-centered problem solvingVthe ultimate outcome of any patient
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Feature Article Table 2. Interprofessional Collaborative Practice Competency Domains and Specific Competency Examples Competency domain 1: values/ethics VE2. Respect the dignity and privacy of patients while maintaining confidentiality in the delivery of team-based care. VE10. Maintain competence in one"s own profession appropriate to the scope of practice. Competency domain 2: roles/responsibilities for collaborative practice RR1. Communicate one"s roles and responsibilities clearly to patients, families, and other professionals. RR5. Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide care that is safe, timely, efficient, effective, and equitable. Competency domain 3: interprofessional communication CC1. Choose effective communication tools and techniques, including information systems and communication technologies, to facilitate discussions and interactions that enhance team function. CC5. Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. Competency domain 4: interprofessional teamwork and team-based care TT3. Engage other health professionalsVappropriate to the specific care situationVin shared patient-centered problem solving. TT4. Integrate the knowledge and experience of other professionsVappropriate to the specific care situationVto inform care decisions, while respecting patient and community values and priorities/preferences for care. Source: American Association of Colleges of Nursing et al3 (2011).
assessment. In this example, the AGCNS competency provides a general view of the CNS assessment. The CNS GPNCE enhances the assessment. Finally, the interprofessional competency helps to focus the assessment in the direction of a measureable outcome, underpinned by the entire team’s assessment (knowledge and experience of other professions). Other sets of competencies are complementary in other ways. For example, one of the nurse sphere/coaching AGCNS competencies already is team focused (eg, assists healthcare team members to integrate the needs, preferences, and strengths of the patient into the healthcare plan to optimize health outcomes). The CNS GPNCE that is related to this competency is that he/she needs an understanding of the different team members’ roles. Finally, one of the communication-focused interprofessional competencies can be used to highlight the importance of the CNS (and other team members), maintaining continuous quality by providing instructive feedback to team members. In essence, the interprofessional competency moves the nurse sphere to a team sphere function for the AGCNS. As is commonly known, aging older adults with chronic illnesses are complex and best managed from a team perspective,23Y25 and so these 3 competencies reinforce that important concept. As can also be seen in Table 3, there is a quality and safety focus across all 3 samples of competencies. The AGCNS student should have numerous opportunities to observe CNS leadership in the area of quality and safety because CNS preceptors frequently chair nursing quality and patient safety committees. The goal in highlighting 328
interprofessional participation and leadership would be to encourage AGCNS students to attend system-level quality and patient safety committee meetings where directors of quality and risk management departments, along with medical doctors (MDs) and other healthcare professionals, are presenting and discussing issues that impact the organization’s accreditation and licensing. Learning activities can be designed to incorporate the features of all 3 sets of competencies. For example, a CNS patient sphere interprofessional case study or a simulation exercise addressing assessment; care planning; nurse, MD, and pharmacy activities; and outcomes reporting through a communication mechanism could be designed for older adults experiencing depression. The development of a CNS nurse sphere teaching plan for staff nurses and social workers could be assigned on the topic of assessing anxiety and substance misuse among older adults. Finally, a CNS organizational sphere capstone project could address the implementation, monitoring, and indicator outcomes for an evidence-based delirium prevention program for older adults. Such a project would emphasize the identification of key stakeholders in the early phase so that the CNS student could incorporate an interprofessional focus to the entire project including the design, implementation, and evaluation phases.
INFRASTRUCTURE TO ADVANCE AGCNS STUDENT KNOWLEDGE AND SKILLS Innovation in education strategies integrating GPN must be directed toward collaborative courses taught by faculty
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Table 3. Sample Complementary Competency Matrix Linking Adult-Gerontology CNS Competencies to CNS Geropsychiatric Competency Enhancements and Interprofessional Collaborative Practice Education Competencies Adult-Gerontology CNS PopulationFocused Competencies4
CNS Geropsychiatric Competency Enhancements2
Interprofessional Collaborative Practice Education Competencies3
Patient sphere/direct care competency
Direct care
Values/ethics
Conducts a comprehensive, holistic assessment of individuals including those who are nonverbally, developmentally, functionally, and/or cognitively impaired (A-1).
Identifies and assesses factors that affect mental health including stressors that may be more common among older adults such as caregiving, multiple chronic illnesses, pain, relocation, trauma, cohort-specific stressors and losses such as financial (retirement), functional limitations (instrumental activities of daily living/activities of daily living), changes in social network (death of family members and friends), and role (status changes) (A).
Maintain competence in one"s own profession appropriate to the scope of practice (V10).
Nurse sphere/coaching competency
Collaboration competency
Interprofessional communication
Assists healthcare team members to integrate the needs, preferences, and strengths of the patient into the healthcare plan to optimize health outcomes (B-1).
Demonstrates knowledge of the similarities and differences in roles of the various healthcare professionals (D).
Give timely, sensitive, instructive feedback to others about their performance on the team and respond respectively as a team member to feedback from others (CC5).
Interprofessional teamwork and team-based care Integrate the knowledge and experience of other professionsVappropriate to the specific care situationVin shared patient-centered problem solving (TT4).
Systems/organizational sphere
Systems leadership competency
Roles/responsibilities for collaborative practice
Provides leadership to address threats to healthcare safety and quality in the adultYolder adult populations (C-4).
Participates in quality improvement initiatives designed to improve care for older adults with mental illness and cognitive impairment (C).
Use the full scope of knowledge, skills, and abilities of available health professionals and healthcare workers to provide safe, timely, efficient, effective, and equitable care (RR5).
Abbreviation: CNS, clinical nurse specialist.
from all the health sciences, including interprofessional simulation experiences and clinical practice such as rounding with all disciplines. Achieving this goal will first require partnerships among deans representing health sciences schools within and between universities. Where barriers are encountered, expert consultants in interprofessional education may need to play a role in making recommendations for such education to convince key stakeholders. Consultancy models to promote interprofessional collaboration have been effective in healthcare organizations26 and may also be effective in academic settings. Second, because change can be disruptive and therefore be resisted by some faculty, we recommend a faculty person be designated to champion the implementation of the additional competencies into the curriculum. Using healthcare administrators as champions, including implementing interdisciplinary practice in a clinical setting, has been successful.27 Such champions influence the structure and culture within organizations so that interprofessional practice change happens. In fact, Begun et al27 have identified 17 administrator competencies for the support of interdisciplinary practice. One example of an administrator competency includes strengthening collaborating connecClinical Nurse Specialist
tions among the professions of nursing, medicine, and pharmacy. This has been accomplished by supporting collaborative work on clinically based projects and encouraging the professionals to be guest speakers in each other’s departments. A second example includes developing organization-wide interprofessional culture. The goal here is to lead the incorporation of the organization’s ‘‘vision, values, symbols, norms, stories, ceremonies, and rituals’’ into an interprofessional mission.27(p121) Similar champions may be equally successful in universities. Finally, although many CNSs are employed in hospital settings, it is important to expand clinical settings beyond the hospital to include community, clinic, assisted living, and nursing home settings. From both a geropsychiatric content and interprofessional culture perspective, professional roles can differ based upon the setting.28 For example, whereas the CNS may lead the team in the hospital setting, a nurse practitioner or MD may take the lead in the clinic setting. Practice in multiple settings will allow the AGCNS student to experience leadership, as well as supportive roles, when caring for older adults with complex P/MH illnesses. In the long term, practice outside the hospital setting will allow AGCNS students and their faculty to
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Feature Article contribute to improving the quality of transitions from 1 setting to another, a critical need for older adults experiencing P/MH illnesses.
ONGOING PROGRAM DEVELOPMENT Whether concerns are with patient, nursing, system, or academic improvements, sustaining gains and advancing programs can be problematic. We offer a number of suggestions for faculty who implement the recommended competencies such as joining key professional organizations and special interest groups and regularly attending conferences. Schools of nursing’s AGCNS faculty can take advantage of joining and playing a prominent role in interprofessional organizations such as the American Geriatrics Society and the Gerontological Society of America. Attending these organizations’ conferences will keep AGCNS faculties up to date with the latest geropsychiatric evidence. Interprofessional special interest groups exist within each of these organizations, and these are quite helpful for networking around certain topics such as Alzheimer’s disease, ageism, and ethical dilemmas. Of special interest is that there is a growing cadre of gerontological nursing leaders within the Gerontological Society of America who make up the membership of the GPNC Work Group. The focus of this work group is to improve GPN care from an interprofessional perspective through education, practice, and research.29 Collaborative working GPNC sessions are scheduled annually to include interprofessional geriatric and gerontological faculty, clinicians, and researchers. Participation in this group will ensure that AGCNS faculties are up to date on the latest GPN nursing, social work, medical, and interprofessional evidence, while also allowing for a dialog about the latest pedagogy and providing opportunities for research and publishing. Such experiences infuse GPN education with fresh ideas so that faculties returning to their campuses sustain gains made in previous years and advance their AGCNS programs in terms of GPN. CONCLUSIONS Geropsychiatric nursing and interprofessional practice is essential for the care of older adults with P/MH illnesses across all settings. Teams of providers have the advantage of combining their expertise to make the best practice decisions. Additional competencies for GPN and interprofessional education can be combined with AGCNS competencies to ensure a competent CNS workforce. These AGCNSs will be better prepared to work on interprofessional teams and thereby meet the needs of the growing population of older adults with P/MH illnesses, ensuring the delivery of safe patient care and excellent patient outcomes. 330
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