Journal of Psychiatric and Mental Health Nursing, 2014, 21, 698–714

Role performance of psychiatric nurses in advanced practice: a systematic review of the literature Y. L . F U N G 1 M A S W W. T . C H I E N 2 P h D

MPHC BN RMN, Pg Di

p NEd u

Z. CHAN2

Ph D MPHC MA BHS RN

&

BN RMN RTN

1

Advanced Practice Nurse (Psychiatric), Department of Child and Adolescent Psychiatry, Castle Peak Hospital, and 2Assistant Professor, and Professor, School of Nursing, The Hong Kong Polytechnic University, Hong Kong

Keywords: advanced practice, mental health, systematic literature reviews Correspondence: Y. L. Fung Department of Child and Adolescent Psychiatry Castle Peak Hospital 15 Tsing Chung Koon Road, Tuen Mun, New Territories Hong Kong E-mail: [email protected] Accepted for publication: 7 November 2013 doi: 10.1111/jpm.12128

Accessible summary

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Psychiatric advanced practice nurses perform multifaceted roles and demonstrate significant results in managing clients with depression and psychological stress, and community-dwelling individuals with mental health-care needs. Psychiatric advanced practice nurses can potentially develop collaborative partnerships with non-mental health service providers, services that are more accessible to users of mental health-care service, and services that enhance the quality of inpatient care. Psychiatric advanced practice nurses need to demonstrate their competence in providing cost-effective interventions through well-designed studies or randomized controlled trials.

Abstract This paper discusses findings from a systematic review of literature pertaining to the role performance of psychiatric nurses in advanced practice. A search of 11 electronic databases was conducted to identify research involving interventions by psychiatric (or mental health) nurses in advanced practice. A total of 14 studies were identified. In this review, the role performance of psychiatric nurses in advanced practice was categorized into three themes: (1) the provision of psychosocial interventions; (2) the provision of nurse-directed services in health-care contexts; and (3) the provision of psychiatric nursing consultation services. Our results document that psychiatric nurses in advanced practice perform multifaceted roles and provide mental healthcare services in various contexts. This systematic review reveals that the nurses obtain significant results in managing clients with depression and psychological stress, and demonstrates their value when developing partnerships with non-mental health service providers. One study, however, showed that the nurses had insignificant results in performing transitional care for pre-discharged mental health service users.

Introduction The increasing complexity of health services, the structural changes in health-care delivery, and changing health-care needs have highlighted the need to investigate and provide innovative as well as expanded health-care options to the global population. Increasing recognition of these needs 698

can provide opportunities for nurses with advanced professional knowledge and skills to enhance and expand the delivery of health-care services globally (International Council of Nurses 2009), including mental health professionals who can provide cost-effective services for people with mental health problems (Cornwell & Chiverton 1997). © 2013 John Wiley & Sons Ltd

Systematic review on role performance of psychiatric APN

Definitions of nurses in advanced practice vary, with each professional association and professional interest group having their own definition. For example, in the USA, the AMA (2010) defines an advanced practice registered nurse (APRN) as ‘a nurse who has completed an accredited graduate-level program preparing her or him for the role of certified nurse practitioner . . . ; maintains continued competence as evidenced by recertification; and is licensed to practice as an APRN’ (p. 63). In Canada, the Canadian Nurses Association (2013) recognizes the nurse practitioner (NP) and the clinical nurse specialist (CNS) as performing advanced nursing practice. Clinical nurse specialists provide expert nursing care and play a leading role in the development of clinical guidelines and protocols. Nurse practitioners also provide direct care and can diagnose, order, and interpret diagnostic tests, prescribe medications, and perform certain procedures. To facilitate an understanding of the emerging roles of NPs and advanced practice nurses (APNs) globally, as well as to guide role development, the International Council of Nurses (ICN) has developed the following definition: A nurse practitioner/advanced practice nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level (International Council of Nurses n.d., p. 1).

This ICN definition emphasizes that nurses in advanced practice are an elite group of nurses who possess advanced competence and higher qualifications, and whose practice is shaped by the local context. However, this definition only provides a broad description of nurses in advanced practice; thus, it is unclear which roles truly reflect advanced practice. It is suggested that a clearer description of the APN’s roles is needed. Psychiatric mental health nursing is a specialized area of nursing practice that provides comprehensive services along the continuum of care for people with mental healthcare needs (Psychiatric Mental Health Nursing Scope and Standards 2006). In order to recognize the contributions of psychiatric nurses to mental health services, it is crucial to re-examine their dimensions of practice, thus providing evidence of their role performance and substantiating their value and functional advancement in mental health-care services. In this paper, we will use ‘psychiatric’ as a generic term for mental health and ‘APN’ for nurses practicing at an advanced level, but will use terms such as NP or CNS if those terms are used in specific countries. © 2013 John Wiley & Sons Ltd

Background In recent decades, APNs have been emerging globally. Sheer & Wong (2008) examined the development of APN practice among 14 countries across five continents. They found that the pace of the development varies in those countries, and that the USA has the longest history of APN development. They also found that APNs emerged as a result of the need to contain costs, improve access to care, reduce waiting times, serve the underprivileged, and maintain health among specific groups. Although the stages in the development of APNs differ in different contexts, there are to a certain extent equivalent nursing roles in local contexts when related to the global concepts. Although the roles of psychiatric APNs have existed for decades, their role performance remains unclear. This may be because there is insufficient knowledge about the roles and performance of psychiatric APNs. There is no agreement on the definition of the psychiatric APN, and little information is available about the actual dimensions of psychiatric APN practice (Campbell et al. 1998). There is also no single set of core competencies to define the psychiatric APN (Wheeler & Haber 2004). This may result in a wide variety of demands or expectations of the psychiatric APN. Within the psychiatric nursing profession, documenting the nature of each aspect of the performance of psychiatric APNs can help to determine their impact on mental healthcare service. The aim of this systematic review is to examine and disseminate the available evidence on the role performance of psychiatric APNs. Understanding the psychiatric APN’s role performance is particularly important for health-care professionals and relevant stakeholders who are concerned about the practice of mental health care and the development of psychiatric nursing services.

Methods Search strategy In October 2012, a search for relevant studies published from 1997 to 2012 was conducted by searching the following 11 electronic databases: Allied and Complimentary Medicine (AMED), the British Nursing Index, Cumulative Index to Nursing and Allied Health (CINAHL), Psychological Information Database (PsycINFO), Excerpta Medica Database (EMBASE), Ovid Medical Literature Analysis and Retrieval System Online [MEDLINER(R)], Journals @ Ovid, Medline, Cochrane (OvidSP), Education Resources Information Center (ERIC), and the Cochrane Library. The following keywords were used: ‘advanced practice nurse or CNS or nurse practitioner or nurse clini699

Y. L. Fung et al.

Potentially relevant studies identified by search strategy N = 1117

Articles excluded, after screening title Total abstracts screened

N = 624 (by authors YLF & ZC)

N = 493 (by authors YLF & ZC) Articles excluded, after screening the abstract N = 476 Total full papers screened N = 17 (by authors YLF & ZC) Articles excluded, after full text reading N=3 Total full papers accepted N = 14 Articles included, after reference list search for additional paper Total full papers accepted for synthesis

N = 0 (by author YLF)

and underwent quality assessment N = 14 (by authors YLF & ZC)

cian’ and ‘mental health or psychiatric’ and ‘assessment or intervention or evaluation or nurse-led or nurse-run or nurse-directed or service.’ Citations from the reference lists of the reviewed articles were also searched to ensure that significant work would not be missed. The search comprised research published in English and that examined services or interventions provided by psychiatric APNs. Studies were assessed to meet a set of inclusion criteria. Two reviewers (YLF and ZC) independently assessed and extracted the studies to be included.

Criteria for considering studies Publications were included for initial screening if they were original articles and full reports of research that met all of the following inclusion criteria: (1) dated no earlier than the year 1997; (2) a primary study (quantitative or mixed method); (3) involved psychiatric APNs in psychiatric service or psychosocial interventions; (4) reported intervention outcomes or findings on psychiatric APNs; and (5) published in English. Qualitative studies were excluded in this review because of a large disparity on the data and findings between the quantitative and qualitative studies. Inclusion of qualitative studies would have resulted in a large volume of publications, and it seemed unlikely that any substantial conclusions would be drawn from the qualitative studies. With a lack of any systematic review or meta-analysis on the topic, we chose to search and explore the topic from the quantitative studies only. 700

Figure 1 Flow diagram showing systematic review protocol

Assessment of relevance for inclusion The initial search identified 1117 articles. After screening titles and abstracts for the relevance of each article to the topic of this review, 17 articles were found to be relevant and thus were retrieved in full text. The 17 full text articles were reviewed to determine whether the inclusion criteria had been met. Two authors (YLF and ZC) read the articles and assessed them independently. Three studies were excluded: the ‘walk-in nurse’ in Crismani & Galletly (2011)’s study could not be identified at the level of advanced practice; and the studies by Wand et al. (2010a) and Wand et al. (2010b) used the same samples and reported similar findings as in one of the included articles. The remaining 14 articles were retained for review. Following the same procedure, citations from the reference lists of previously gathered articles were also searched. No additional articles met the inclusion criteria. Figure 1 shows the flow diagram of the systematic review protocol.

Assessment of the quality of the studies All the included studies underwent a quality assessment. The checklist developed by Downs & Black (1998) for measuring the methodological quality of a study was used. The checklist consisted of 27 items distributed between five domains: (1) reporting (items 1–10), e.g. description of the hypothesis/aim/objective, outcomes measure, intervention, and findings; (2) external validity (items 11–13), e.g. the © 2013 John Wiley & Sons Ltd

Systematic review on role performance of psychiatric APN

subjects asked to participate in the study representative of the entire population from which they were recruited; and the staff, places, and facilities where the patients were treated representative of the treatment the majority of patients received; (3) internal validity – bias (items 14–20), e.g. an attempt made to blind study subjects to intervention they have received and those measuring the main outcomes of the intervention, and the statistical tests used to assess the main outcomes appropriate; (4) internal validity – confounding (items 21–26), e.g. the patients in different intervention groups recruited from the same population, and study subjects randomized into intervention groups; and (5) power (item 27), e.g. the size of the smallest intervention group. Answers were scored 0 or 1, except for one item in the reporting domain, which scored 0 to 2, and the single item on power, which was scored 0 to 5. The possible score range for the reporting domain was 0 to 11, that for the external validity domain was 0 to 3, the internal validity (bias) domain was 0 to 7, the internal validity (confounding) domain was 0 to 6, and the power domain was 0 to 5. The total score range was 0 to 32. The higher the score, the higher the quality of the article on the aspect being rated. The 14 studies involved randomized controlled trials (n = 3), quasi-experimental or longitudinal evaluative studies (n = 9), and mixed methods (n = 2). The scores of the 14 studies ranged from 18 (Beeber & Charlie 1998, Sharrock & Happell 2002) to 31 (Hanrahan et al. 2011). The first author (YLF) and one co-author (ZC) reviewed and scored the studies and discussed their ratings. Any differences in ratings were clarified until a consensus was reached. Data were extracted from the selected studies using a basic data extraction form with sections consisting of total scores on methodological quality, aim/objectives/ hypothesis, design, sample size/targeted clientele, theoretical model, psychiatric APN’s intervention, outcome measures, and psychiatric APN’s role performance and main results. All disagreements on the study and on the inclusion of information were resolved by consensus among the members of the research team.

model (Knight & Houseman 2008), the Interaction Model of Client Health Behavior (IMCHB) (Price 2007), and an integration of Caplan’s model with a liaison model (Sharrock & Happell 2002). The use of a theoretical model to guide the practice of APNs helped to guide the intervention strategies and to align appropriate outcome measures that were congruent with the theoretically predicted benefit of the intervention.

Samples There were a broad range of samples in the studies that were included in the review and most of them had small samples. The smallest involved 13 subjects in a post-test only design study (Price 2007); the largest involved 1030 secondary school students in a longitudinal, quasiexperimental field study (Hardin et al. 2002). One study did not mention the number of participants in the control group in their randomized controlled study (Beeber et al. 2007). The study by Sharrock & Happell (2002) did not report the total number of participants in the focus groups.

Aims of the selected studies The 14 studies reviewed reported different aspects of the role and performance of psychiatric APNs. Their aims were mainly to test the feasibility of the assessment and the intervention model in diverse groups of patients with mental health problems, or to examine the effectiveness of the nurse-directed services in different health-care contexts; or to examine the impact of the psychiatric nursing consultation service in various care contexts.

Methodologies employed The 14 identified studies included designs from randomized controlled trials to pretest–post-test control groups, and from longitudinal comparison groups to mixed methods. Table 1 presents the details of each included study.

Results Findings Fourteen studies met the criteria for inclusion in this review. The studies were conducted in the USA (n = 11), Australia (n = 2), and the Republic of Ireland (n = 1). Seven studies used nursing or health-care models to guide the intervention: Peplau’s interpersonal theory (Beeber & Charlie 1998, Beeber et al. 2007), Orem’s Self-Care Deficit Theory and Nurse-Directed Care Model (NDCM) (E-Morris et al. 2010), the care management model (Hanrahan et al. 2011), the nurse-physician collaborative © 2013 John Wiley & Sons Ltd

The role of the psychiatric APN Among the 14 articles, only one directly examined the role of the psychiatric APN. This study was conducted by Sharrock & Happell (2002), who presented the model of practice of the psychiatric consultation liaison nurse (PCLN) and a brief overview of the roles of the PCLN in case and administrative consultations, and in liaison in a general hospital. Other reported activities or interventions included: providing psychiatric nursing consultation 701

702

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18

Beeber & Charlie (1998) USA

Scores on methodological quality

Baradell & Bordeaux (2001) USA

Author/year/ country

– To test the feasibility of a depressive symptom screening and intervention initiative in a primary care setting

– To describe the clinical outcomes and level of satisfaction of patients whose psychotherapy was provided by CNSs

Aim, objectives and/or hypothesis

Pre-experimental, one-group pretest–post-test study

Prospective study

Design

Table 1 Description of the main components of the 14 studies reviewed

– Women consecutively screened and referred by primary care nurses, nurse practitioners, and physicians in a health centre (n = 33)

– Patients from private practices of 12 psychiatric CNSs (n = 257)

Sample size/targeted clientele

– Peplau’s interpersonal theory

N/A

Theoretical model

– Screening for depressive symptoms with BDI; scores ≥10 were offered intervention – 21 women were given additional pre- and post-test instruments after screening – Establish a therapeutic relationship, assessing life transitions, investigating the role of depressive symptoms in the woman’s management of anxiety, and understanding depressive symptoms in the context of self and relations

– Psychotherapy

Psychiatric APN’s intervention

– Pre- and post-test measures of the responses of the women to the intervention effect. – Four main response indicators: depressive symptoms, efficacy self-esteem, social self-esteem, and satisfaction with interpersonal relations

– Survey: clinical symptom using the POMS-SF, QOL, and patient satisfaction using the PSS – POMS-SF and QOL measured at the initial clinical evaluation, termination, and 6 months after termination – PSS measured 6 months after termination

Outcome measures

– All 33 women scored above 10 on BDI at the pre-intervention. 27 women scored below 10 at post-intervention. – There was an increase in the mean efficacy self-esteem score post-intervention, but social self-esteem and satisfaction with interpersonal relations showed little change. – There was a significant difference between the pre- and post-intervention BDI scores (t = 8.765, d.f. = 29, P = 0.0005) in a paired sample t test.

– Total POMS-SF scores: significantly reduced at termination (M = 30.97; SD = 14.05) compared with scores at initiation (M = 51.93; SD = 17.46), F(1,149) = 209.21 Mean Standard Error = 157.50, P < 0.0001. The changes of scores between termination and 6-month follow-up, and the changes in symptoms were not clinically significant. – Total QOL scores: significantly increased at termination (M = 115.27; SD = 20.66) compared with scores at initiation (M = 103.11; SD = 20.83), F(1,148) = 55.95, Mean Standard Error = 204.59, P < 0.0001. The changes of scores between termination and 6-month follow-up, and the changes in symptoms were not clinically significant. – Patients reported of satisfaction with factors related to the interpersonal relationship with the CNSs ranged 97% to 99%.

Psychiatric APN’s role performance/main results

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Beeber et al. (2007) USA

E-Morris et al. (2010) USA

– To describe a quality improvement project focusing on the process of implementing a new nursing model in one building of the hospital to increase the accountability for person-centred interventions

– To address what barriers to care as nurses implemented the psychotherapy intervention and what relationship-based strategies were used by nurses to establish and maintain a therapeutic interpersonal relationship

Pretest–post-test design

Randomized controlled trial (mixed research methods)

– Staff and clients in one building in a psychiatric hospital – 32 staff completed pre-measures and – 52 staff and 19 clients completed post-measures

– Low-income mothers who scored ≥16 on the CESDS – Intervention group (n = 29) – Control group: not specified

– Dorothea Orem’s Self-care Deficit Theory. – NDCM

– Peplau’s interpersonal theory

– Ongoing clinical supervision by the unit APN to help staff link the day-to-day interventions to the client’s treatment plan goals

– 10 face-to-face sessions in the mothers’ homes – Five additional booster contacts provided to deliberately attenuate the intensity of the face-to-face contact and allow the mother to carry out intervention strategies on her own

– Survey on staff and clients to assess their knowledge of treatment plan goals and other clinical issues, and to observe the clients’ living condition – The information was verified for accuracy by reviewing the medical record and posted NDCM master list and assignment sheets. Baseline measures at the initial phase of the implementation process and follow-up measures were done 9 months later.

– The frequency of the 19 relationship-based strategies in the component checklist used by the intervention nurses; and – Content analysis on the Psychiatric APNs’ written records: chronological account of each visit, which described the home setting, the nurse’s interventions with the mothers, the specific intervention protocols used, and nurses’ thoughts and feelings

– Significant differences were found for de-escalation, 50% in 2005 vs. 90% in 2006 (t28 = 2.96, P < 0.01) – There were improvements in almost all environmental aspects of care from 2005–2006. Significant differences were found for the number of showers, 37.5% in 2005 vs. 77.4% in 2006 (t39 = 3.42, P < 0.001); adequate clothing, 22% in 2005 vs. 80% in 2006, t31 = 5.4, P < 0.001). – Comparison of incidences of seclusion and restraint between buildings: Building A (144 beds; full implementation of the NDCM) had 16 and 22 episodes, and building C (97 beds; less than full implementation of the model) had 25 and 64 episodes in 2005 and 2006, respectively.

– The strategies most frequently used by intervention nurses to retain mothers: in person contact (98%), encouragement (90%), and empathy (60%). – Three primary barriers to and factors in engaging and retaining mothers: the challenge of making the initial face-to-face contact with the mothers, the mother’s multiple severe life events and chronic pressures, and the nurses’ work engendered anxiety in the mother.

Systematic review on role performance of psychiatric APN

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Hardin et al. (2002) USA

Design

– To examine the effects of a long-term psychosocial nursing intervention designed to decrease adolescents’ mental distress following their exposure to Hurricane Hugo. Longitudinal, quasi-experimental, field study

– By 12-month Longitudinal follow-up, the randomized patients receiving controlled trial the home-based psychiatric APN intervention would have experienced greater improvements in symptoms and quality of life than the control group – A higher psychiatric APN dose would be associated with a reduction in psychiatric symptoms and improved HRQOL

Scores on methodological Aim, objectives quality and/or hypothesis

Hanrahan et al. (2011) USA

Author/year/ country

Table 1 Continued Psychiatric APN’s intervention – Changes in psychiatric symptoms and HRQoL over the 12 months of intervention – HRQoL was measured with the Medical Outcomes Study SF-12 – Psychiatric symptoms were measured with the PHQ-9 and the Colorado Symptom Index (CSI). – Nurse dose: combination of the time, the intensity of the need, and the duration of the psychiatric APN intervention. Dose level X time interaction to calculate the ATE and measured at four time points: baseline to 3 months, 3 months to 6 months, 6 months to 12 months , and baseline to 12 months.

Outcome measures

– Structured Catastrophic – Survey on mental distress Stress Intervention (SCSI) measured using the involved three Derogatis BSI at baseline, sessions/year, for 3 years: 6, 12, 18, 24, 30, and 36 – Didactic and months post-intervention. problem-solving methods to increase adolescents’ cognitive understanding of stress and healthy coping; – ‘Opra Win-Free’ mock television show format to explore ways in which adolescents could increase their social support; and – Art and visual imagery to enhance the adolescents’ sense of self-efficacy

Care – Weekly face-to-face or management phone contact with model participants – Obtain a full health assessment – Establish a plan of care in collaboration with the client – Work closely with each client’s case manager, boarding homes, shelters, pharmacies, and clinical providers. – Attend appointments with the client and, with the client’s permission, sharing updates in treatment regimens – Advocate for the client with providers and coached clients to interact more effectively with their providers.

Theoretical model

– 1030 students in N/A two South Carolina high schools: – Intervention participants or assigned/nonparticipants (n = 480) – Control (n = 550)

– 238 communitydwelling individuals with SMI/HIV – Intervention group (n = 128) – Control group (n = 110)

Sample size/targeted clientele

– Adolescents in the SCSI had less mental distress over time than the control adolescents. – When using the first two time points (n = 1030), there was a significant SCSI effect (P = 0.0001). – When using the first four time points (n = 810; 21% attrition in all subjects), there was a significant intervention effect (P = 0.006). – When all six time points were used (n = 669; 17% attrition in all subjects), there was a marginally significant intervention effect (P = 0.06)

– CSI scores: both groups experienced decreases in CSI score from baseline to 12 months but the difference was not significant (d = −4.03, P = 0.51 95% CI = −15.99, 7.83) – PHQ-9 scores: decreased in control group (d = −1.23, P = 0.54, 95% CI = −2.48, 0.02); increase in experimental group (d = 3.17, P = 0.37 95% CI = −3.78, 10.11). – SF-12 scores: non-significant (P > 0.05) indicating no clear difference in the changes in these measurable outcomes over time between two groups. – Dose-outcome analysis: • High-dose participants: reduction in CSI scores at each of the four time panels. ATE for the 6–12-month period: −5.63 (P = 0.05, 95% CI = −11.2, −.0.01), and −3.69 from baseline to 12 months (P = 0.102, 95% CI = −8.1, 0.70). From baseline to 12 months, experienced an average decrease in PHQ-9 score of 5.314 points (P < 0.01, 95% CI = −7.4, 3.16). • Moderate-dose participants: CSI scores decreased more than for participants. ATE for 3–6 months: 0.49, P = 0.80, 95% CI = −3.3, 4.3). From baseline to 12 months, ATE: −0.40 (P = 0.79, 95% CI = −3.4, 2.6). • Low-dose participants: No distinguishable differences in reduction of CSI scores. From baseline to 12 months, ATE: −1.07 (P = 0.502, 95% CI = −4.12, 2.1).

Psychiatric APN’s role performance/mainresults

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– Null hypothesis: Quasi-experimental, (1) no difference non-equivalent-groups on depression design assessment scales (HAM-D/GDS) between groups or from baseline to evaluation (2) no difference on functional assessment: activity of daily living and instrumental activity of daily living summaries

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Knight & Houseman (2008) USA

Descriptive, non-experimental design

– To provide a profile of patients seen by the PCLN – To describe the outcomes of the PCLN consultation and assessment

Johnston & Cowman 20 (2008) Republic of Ireland N/A

– Aged over 65 with N/A HAM-D or GDS scores > 10 – Self-selected into either treatment or non-treatment group – Treatment group (n = 36) – Non-treatment group (n = 5)

– Patients referred and assessed by the PCLN (n = 66)

– Treatment group – Assessments at baseline intervention: psychotropic and endpoint using the medication management; following instruments: primary care physician HAM-D; GDS;15 OASIS consultation/telephone contact; individual supportive psychotherapy; client/family education; medication social work referral. – Non-treatment group intervention: skilled nursing; physical therapy, occupational therapy; social work; and home care aid services.

– Direct intervention: – Questionnaire: the staff assessment, planning and most involved in the evaluation of patients patients’ care completed – Indirect intervention: part one and returned it to liaison, education, support, the PCLN; part two and advice to other health completed by PCLN, professionals responsible related to the specific for the care and treatment details of the patients’ of the patient assessed and provided insights into the depth of the service provision by the PCLN

– HAM-D: no significant decline for the non-treatment group; a significant decline for the treatment group (a decrease of 6.3, 95% CI = 4.2, 8.3) – GDS: no significant decline for the non-treatment group; a significant decline for the treatment group (a decline of 4.4, 95% CI = 2.5, 6.4) – Functional score: a significant improvement in both groups. A decline in impairment score of 3.4 (95% CI = 0.4, 6.4) for the non-treatment group; 1.9 (95% CI = 0.7, 3.0 for treatment group)

– Patient profiles: 52% female, 55% single, 33% married, and 12% widowed, divorced or cohabiting; aged from 17–71; 53% had a past psychiatric history. – Admission profiles: 77% medical issue, 23% and 55% of this patient group presented with a parasuicide attempt – PCLN referral: 41% for parasuicide, 24% for a current mental state examination. – Patient diagnosis: a significant difference between the diagnosis provided by the PCLN and the reason for the referral (Pearson chi-square = 36.885, d.f. = 16, P = 0.002) – Outcome of PCLN assessment: 49% referred to the psychiatrists’ outpatient clinic, patient admitted to the psychiatric unit, 83% had a past psychiatric history, 63% discharged to GP without a past psychiatric history – Psychiatrists involvement: 4 cases

Systematic review on role performance of psychiatric APN

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McCorkle et al. (2011) USA

Scores on methodological quality

McCorkle et al. (2009) USA

Author/year/ country

Table 1 Continued

– To evaluate the effectiveness of an intervention provided by APN + PCLAPN on patients’ self-report of healthcare utilization compared with an attention control intervention in women undergoing surgery for a suspected diagnosis of ovarian cancer.

– To report the effects of a nursing intervention on quality of life outcomes in post-surgical women with gynaecological cancers

Aim, objectives and/or hypothesis

A two-group experimental, longitudinal design

Single-blind randomized clinical trial

Design

– Woman suspected primary diagnosis of ovarian cancer after abdominal surgery. – Intervention group (n = 59) – Attention control group (n = 62)

– 123 post-surgical women suspected of having a primary diagnosis of ovarian cancer: – Intervention group (n = 63) cared for by an oncology APN; 32 women (subgroup) with high distress were evaluated and monitored by a PCLAPN – Control (n = 60)

Sample size/targeted clientele

N/A

N/A

Theoretical model

– 18 contacts by an oncology APN during the first 6 months after hospital discharge. – Intervention group (30 of 59 women) who scored greater on the distress thermometer received an evaluation by the PCLAPN. Based on the PCLAPN evaluation, the APN developed a collaborative plan of care targeting the patient’s specific emotional needs. – The attention control received 9 contacts by a research assistant during the 6 months. – Both groups received the Symptom Management Toolkit.

– 1–2 additional clinic/home visit(s) for evaluation telephone follow-up – Psychiatric evaluation in cases of high emotional distress – Develop collaborative treatment plan, identification of resources and referral

Psychiatric APN’s intervention

– Health-care utilization data: numbers of inpatient admission and outpatient visits – Depressive symptoms: 20-item CESDS – Uncertainty: MUIS distress: SDS. – Data collected at baseline within 48 hours after surgery and 1, 3, and 6 months after surgery.

– Self-report questionnaires administered at baseline, 1, 3, and 6 months post-surgery. Quality of life assessments included the CESDS, the ambiguity subscale of the MUIS, the SDS, and the SF-12.

Outcome measures

– Patients who received the APN intervention reported fewer primary care visits (β = −0.95 ± 0.16, P = 0.0003). Women in the attention control group reported more depressive symptoms (CESDS scores) and better physical health than the intervention group. Intervention provided by the APNs in conjunction with the PCLAPN assisted those women with depressive symptoms, whereas the attention control group sought additional help their primary care providers.

– The oncology APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the subgroup who received the APN + PCLAPN intervention was compared with the total attention control group, the subgroup had significantly less uncertainty (MUIS) (P = 0.0181), less symptom distress (SDS) (P < 0.0001), and better SF-12 mental (P = 0.0001) and physical (P < 0.0001) QOL over time. For the CESDS, there was no significant effect of the PCLAPN (P = 0.64).

Psychiatric APN’s role performance/mainresults

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McDougall et al. (1997) USA

Price (2007) USA

– To test the feasibility of conducting a multisite trial using the Transition to Community programme.

– To examine the process and outcomes of life review therapy provided by an advanced geropsychiatric nurse to older adults discharged from psychiatric hospitals to their homes.

Post-test only design

Longitudinal within-subject comparison

– Schizophrenia/ schizoaffective disorder diagnosed within the previous 60 months and scheduled for discharge to community care -Experimental group (n = 7) – Comparison group (n = 6)

– Adults over 65 years of age with a primary diagnosis of depression (n = 80)

– The IMCHB

N/A

– Conducted a structured interview with clients 2–3 days prior to scheduled discharge – Telephoned the client at least twice between the time of discharge from the hospital and the first scheduled outpatient appointment. – Encouraged participants to call the APPN if any problems arose. – Called the client’s community case manager and reviewed information from the structured interview.

– Life review psychotherapy sessions

– Fisher’s exact test was used to measure the significance of the differences in categorical variables (compliance with the first scheduled outpatient appointment and medication compliance). – The t-test for two independent groups was used to test the hospital readmission days for the two groups.

– Within-subject change in empowerment and disempowerment theme was determined by computing the Wilcoxon signed-rank test on T1 (1st half sessions) and T2 (2nd half sessions) theme data. – To determine changes over time, the themes were divided into empowerment-T1 and T2 and disempowerment-T1 and T2.

– Neither result was statistically significant: for outpatient compliance (P = 0.4126); medication compliance (P = 0.3834); and difference in the means of hospital readmission days for the two groups (P = 0.2389).

– Significant decrease (P < 0.0001) in total disempowerment themes; early phases of treatment (M1 = 13.073, SD = 7.73); as treatment progressed (M2 = 9.14, SD = 6.04). – There were no T1 or T2 differences in empowerment themes.

Systematic review on role performance of psychiatric APN

707

708

21

Wand et al. (2011) Australia

– To reduce the delay in access to mental health intervention for individuals presenting through the ED – To evaluate the feasibility and acceptability of this new service to outpatients with ED staff

– To present a brief overview of the role and model of practice of the PCLN, the means of referral, a profile of consultations and an overview of educational and policy development activity

Aim, objectives and/or hypothesis

Mixed methods (combination of quantitative measures with qualitative analysis)

Mixed methods (survey + focus group)

Design

– Survey: outpatients (n = 101); follow-up postal survey (n = 51) – Interviews: outpatients (n = 23) + ED staff (n = 20)

– Survey: staff who used the services of the PCLN (n = 117) – Three focus groups: 17 nurses + 1 social worker participated in one of three focus groups

Sample size/targeted clientele

N/A

Integration of Caplan’s model with a liaison model

Theoretical model

– The MHNP accepts referral from ED staff – Mental health intervention offered up to five sessions – Returning for mental health intervention would all be triaged, reviewed and discharged by the MHNP

– Case consultation – Administrative consultation – Liaison

Psychiatric APN’s intervention

– Pre-measure: the K-10 measure of psychological stress + the GSES – Post- measure: the K-10 measure of psychological stress + GSES + client satisfaction tool – Semi-structured interview with outpatients and ED staff

– Data on case consultation activity. – Data on administrative consultation. – Survey on degree of satisfaction using Health Professionals Perception Survey – Focus group: thematic analysis

Outcome measures

– Consultation activities of the PCLN: 90 requests; nurses were the primary users (69%; 48% referrals were initiated from the medical units; the problem of risk of self-harm (22%) was the most frequently precipitating a referral; 30% patients were seen directly by the PCLN; and intervention most frequently used by the PCLN was the provision of advice/guidance/recommendations, accounting for 23% PCLN clinical time. – Health professional perception surveys: >90% participants found the services of the PCLN to be timely, accessible, well documented, and professional – Main themes in focus group interviews: making contact; helping staff; processes used by the PCLN; and attributes – K-10 measures: 66% outpatients’ mean score decreased by two categories (P < 0.001) at follow-up – GSES: one point improvement in the mean score at follow-up, improvement in perceived self-efficacy (P = 0.0137) – Client satisfaction tool: strongly agreed with the availability (n = 38, 74.5%); accessibility of the service (n = 35, 68.6%); therapeutic features: support and encouragement received (n = 38, 74.5%); feeling listened to and understood (n = 36, 70.6%); useful information and health education (n = 31, 60.8%); overall standard of care provided (n = 35, 68.6%)

Psychiatric APN’s roleperformance/mainresults

Studies-Depression Scale; CI, confidence interval; CNS, clinical nurse specialist; ED, emergency department; GDS, Geriatric Depression Scale; GP, general practitioner; GSES, General Self Efficacy Scale; HAM-D, Hamilton Depression Scale; HRQoL, health-related quality of life; IMCHB, Interaction Model of Client Health Behavior; MHNP, mental health nurse practitioner; MUIS, Mishel Uncertainty in Illness Scale; NDCM, Nurse-Directed Care Model; OASIS, Outcome and Assessment Information Set; PCLAPN, psychiatric consultation liaison advanced practice nurse; PHQ-9, Patient Health Questionnaire; POMS-SF, Profile of Mood States-Short form; PSS, Patient Satisfaction Survey; QOL, Quality of Life; SCI, Colorado Symptom Index; SCSI, Structured Catastrophic Stress Intervention; SDS, Symptom Distress Scale; SF-12, 12-item Short-Form Health Survey; SMI, serious mental illness.

APN, advanced practice nurse; APPN, advanced practice psychiatric nurse; ATE, average treatment effect; BDI, Beck Depression Inventory; BSI, Brief Symptom Inventory; CESDS, Centre for Epidemiological

18

Scores on methodological quality

Sharrock & Happell (2002) Australia

Author/year/ country

Table 1 Continued

Y. L. Fung et al.

© 2013 John Wiley & Sons Ltd

Systematic review on role performance of psychiatric APN

service to medical teams in a general hospital (Johnston & Cowman 2008), or to APNs for women after surgery for ovarian cancer (McCorkle et al. 2009, 2011); providing psychosocial interventions to women with depressive symptoms (Beeber & Charlie 1998), to depressed lowincome mothers (Beeber et al. 2007), to communitydwelling mental health service users (Baradell & Bordeaux 2001), to homebound individuals with serious mental illness (SMI)/HIV (Hanrahan et al. 2011), to adolescents exposed to catastrophic stress (Hardin et al. 2002), or to depressed homebound older adults (McDougall et al. 1997, Knight & Houseman 2008); providing transitional care to pre-discharged mental health service users (Price 2007); and implementing nurse-directed services in a psychiatric hospital (E-Morris et al. 2010) or emergency department (ED) (Wand et al. 2011). The outcomes of the 14 studies varied from study to study. Given the heterogeneity of the study outcomes, combining the results statistically is impossible. Therefore, narrative descriptions of the outcome measures are provided below, along with a critical analysis and summary of the main outcomes of the study. Three themes emerged as relevant to the role performance of the psychiatric APNs: (1) the provision of psychosocial interventions; (2) the provision of nurse-directed services in health-care contexts; and (3) the provision of psychiatric nursing consultation services.

Provision of psychosocial interventions There were 10 studies that examined the outcomes of the psychosocial interventions of psychiatric APNs. Four involved psychiatric APNs in managing clients with depression (McDougall et al. 1997, Beeber & Charlie 1998, Beeber et al. 2007, Knight & Houseman 2008). Among these four studies, three reported significant positive results of interventions by psychiatric APNs on depressive symptoms in a primary care setting (Beeber & Charlie 1998), or on homebound older adults (McDougall et al. 1997, Knight & Houseman 2008). One study generated information about barriers to and strategies in engaging women with depression through an evaluation of an intervention provided by a psychiatric APN, but did not report any significant results on the outcomes (Beeber et al. 2007). Five studies involved psychiatric APNs in managing individuals with psychological stress: women with cancer (McCorkle et al. 2009, 2011), adolescent students who were under stress (Hardin et al. 2002), individuals with SMI/HIV (Hanrahan et al. 2011), and community-dwelling mental health service users (Baradell & Bordeaux 2001). Significant positive results from interventions by psychiatric APNs were found in all five studies. One study reported © 2013 John Wiley & Sons Ltd

the feasibility of a transitional model of care in preparing inpatients with schizophrenia for discharge to the community (Price 2007). This study did not report any significant outcomes. Beeber & Charlie (1998) tested the feasibility of screening women for depressive symptoms using the Beck Depression Inventory (BDI) and their intervention using Peplau’s interpersonal theory. Although there was little change in the areas of social esteem and satisfaction with interpersonal relations, there was an increase in the mean efficacy self-esteem score post-intervention and a significant difference between the pre- and post-intervention BDI scores (t = 8.765, d.f. = 29, P = 0.0005) in a paired samples t-test. This study showed that it is feasible for a psychiatric APN to carry out an intervention for depressive symptoms in a primary care setting. When caring for depressed lowincome mothers, nurses also need to identify whether they will participate in an intervention. Beeber et al. (2007) identified the barriers to care as nurses implemented a psychotherapy intervention for depressed low-income mothers, and used the relationship-based strategies on a standardized component checklist to identify the strategies used by the nurses to establish and maintain a therapeutic interpersonal relationship. This study found that the challenge of making the initial face-to-face contact with the mothers, the mother’s multiple severe life events and chronic pressures, and the nurses’ work-engendered anxiety in the mother were the three primary barriers to engaging and retaining mothers. This study also identified personal contact (98%), encouragement (90%), and empathy (66%) as the strategies most frequently used by nurses to retain mothers. In addition, psychiatric APNs also provided domiciliary nursing care for depressed older adults. McDougall et al. (1997) examined the process and outcomes of life review therapy provided by a psychiatric APN to 80 homebound older adults; likewise, Knight & Houseman (2008) examined the effectiveness of a psychiatric APN – primary care physician collaborative model to 36 homebound medically ill/depressed older adults using a quasi-experimental, nonequivalent-groups design. In the study of McDougall et al. (1997), there was a significant decrease (P < 0.0001) in total disempowerment themes in the early phases of treatment (M1 = 13.073, SD = 7.73) and as treatment progressed (M2 = 9.14, SD = 6.04). This study suggested that life review therapy conducted by a psychiatric APN could lead to a decrease in negative themes and might be an effective therapy for the homebound elderly with depression. In the study of Knight & Houseman (2008), a significant decline in depression among the treatment group was noted as measured by both the Hamilton Depression Scale [a decrease of 6.3, 95% confidence interval (CI) = 4.2–8.3] 709

Y. L. Fung et al.

and the Geriatric Depression Scale (a decline of 4.4, 95% CI = 2.5–6.4). This study suggested that partnering nurses with physicians is an effective strategy for improving the quality of care delivered to homebound elders with medical and mental health-care needs. Similarly, psychiatric APNs also provided domiciliary services to individuals who were co-morbid with medical and mental problems. Hanrahan et al. (2011), in their randomized clinical trial, evaluated the effectiveness of a home-based intervention for individuals with SMI/HIV. Over 12 months of the intervention by psychiatric APNs, the intervention group showed significant improvement in depression (P = 0.012) and in the physical component of health-related quality of life (QOL) (P = 0.03) from baseline to 12 months. This study demonstrated that the intervention by psychiatric APNs may be a useful strategy for improving care and outcomes for high-need individuals with SMI/HIV. Interventions by psychiatric APNs were also provided to depressed women with cancer. McCorkle et al. (2009) and McCorkle et al. (2011) reported the effects of a nursing intervention in post-surgical women with gynaecological cancers. Women in the intervention group received specialized care provided by an APN, and those women (subgroup) in high distress were referred to a psychiatric consultation liaison advanced practice nurse (PCLAPN). McCorkle et al. (2009), in their randomized controlled trial, reported the effects on these women of a nursing intervention on QOL. The 63 women in the intervention group were found to be in significantly less uncertainty than those in the placebo group at 6 months after surgery. When comparing the 32 women (subgroup) with those in the placebo group, the subgroup participants also indicated significantly less uncertainty in the ambiguity subscale of the Mishel Uncertainty in Illness Scale (P = 0.0181), less symptom distress in the Symptom Distress Scale (P < 0.0001), and achieved better results in the Short-Form Health Survey-12 mental (P = 0.0001) and physical (P < 0.0001) QOL over time. The study showed that the nursetailored intervention provided together by an APN and a PCLAPN that targeted at both physical and psychological aspects of QOL among women cancer patients with depression produced stronger outcomes than those targeted solely at a single aspect of QOL. Similarly, McCorkle et al. (2011) in their two-group experimental, longitudinal study evaluated the effects of an intervention provided by both an oncology APN and a PCLAPN on health-care utilization by post-surgical women with ovarian cancers. An oncology APN provided 18 contacts to 59 women in the intervention group. Thirty out of fifty-nine women in the intervention group who were found to have emotional distress after initial screening by the oncology APN received a focused mental health assessment and review by 710

the PCLAPN. Based on the PCLAPN’s evaluation, the oncology APN developed a collaborative care plan with both the client and the PCLAPN, targeting at individual woman’s specific emotional needs. The women in the intervention group reported fewer primary care visits (β = −0.95 ± 0.16, P = 0.0003) and more visits to the emergency room than those in the attention control group because the nurse instructed patients to go when they recognized symptoms that needed urgent care. Women in the attention control group reported more depressive symptoms and better physical health than those in the intervention group because the intervention provided by the APN + PCLAPN assisted those 30 women in the subgroup, whereas the attention control group sought additional help from their primary care providers. These two studies highlighted the need for health-care providers representing various disciplines to care for women cancer patients with depressive symptoms. A psychosocial intervention provided by psychiatric APNs was also found to be effective in distressed adolescents. Hardin et al. (2002) studied the effects of a long-term psychosocial nursing intervention on 1030 adolescents exposed to catastrophic stress. A Structured Catastrophic Stress Intervention (SCSI) was conducted on adolescents in the intervention group for 3 years. Repeated measures of mental distress using the Derogatis Brief Symptom Inventory were conducted at baseline and at 6, 12, 18, 24, 30, and 36 months post-intervention. At the first two time points (N = 1030), a significant effect was seen from the SCSI (P = 0.0001). Taking the first four time points into consideration (N = 810; 21% attrition), a significant intervention effect was noted from the SCSI (P = 0.006). When all six time points were used (N = 669; 17% attrition), a marginally significant intervention effect was seen (P = 0.06). This study found that the SCSI conducted by psychiatric APNs on the adolescents resulted in less mental distress over time than was found in control adolescents in the first 2 years, but that this difference had dissipated by 30 and 36 months. Alternatively, mental health care can be provided by psychiatric CNSs in private practice. Baradell & Bordeaux (2001) evaluated the clinical outcomes and level of satisfaction of 257 patients whose psychotherapy was provided by 12 psychiatric CNSs. The patients’ clinical symptoms were measured at the initial clinical evaluation, at termination, and 6 months after termination using the Profile of Mood States-Short form (POMS-SF) and QOL. Patient satisfaction was measured 6 months after termination using a patient satisfaction survey. The total POMS-SF scores were significantly reduced at termination (M = 30.97; SD = 14.05) compared with the scores at initiation (M = 51.93; SD = 17.46), F(1,149) = 209.21 MSE = © 2013 John Wiley & Sons Ltd

Systematic review on role performance of psychiatric APN

157.50, P < 0.0001; and the total QOL scores were significantly higher at termination (M = 115.27; SD = 20.66) compared with the scores at initiation (M = 103.11; SD = 20.83), F(1,148) = 55.95, MSE = 204.59, P < 0.0001. The changes in the scores between termination and the 6-month follow-up, and the changes in the symptoms were not clinically significant. The patients reported a high level of satisfaction with the care provided by the CNSs. This study supported the view that mental health care provided by psychiatric CNSs can improve the quality of patient care and suggested psychotherapy as an autonomous role for psychiatric CNSs. In addition, psychiatric APNs provided continuity of care to pre-discharged mental health service users. Price (2007) reported on the feasibility of a transitional model of care involving preparing inpatients with schizophrenia for discharge to the community. Based on the IMCHB model, a psychiatric APN conducted a structured interview with pre-discharged patients, collaborated with the community case manager, and followed-up with the patients after discharge via prepaid cellular phones. No significant improvement in the experimental group was found in either the results of the outpatient follow-up (P = 0.413) and medication compliance (P = 0.383) or in the mean difference in hospital readmission days (P = 0.239). These nonsignificant results indicated the need for the intervention to be modified before being implemented in a larger multisite clinical trial. It is suggested that it is necessary to explore alternative intervention models to enhance transitional care.

Provision of nurse-directed services in health-care contexts Two studies involved testing the feasibility of implementing care models by integrating psychiatric APNs in the contexts of a psychiatric inpatient setting (E-Morris et al. 2010), and in an ED (Wand et al. 2011). Overall, their results showed significant improvement in the care delivered to the patients. E-Morris et al. (2010) described a quality improvement project focusing on the process of implementing the NDCM in one building of a psychiatric hospital to increase accountability in person-centred interventions. Significant differences were found in de-escalation: 50% in 2005 vs. 90% in 2006 (t28 = 2.96, P < 0.01). There were improvements in almost all environmental aspects of care from 2005 to 2006: significant differences were found for the number of showers, 37.5% in 2005 vs. 77.4% in 2006 (t39 = 3.42, P < 0.001); and adequate clothing, 22% in 2005 vs. 80% in 2006 (t31 = 5.4, P < 0.001). A comparison of incidences of seclusion and restraints between building A © 2013 John Wiley & Sons Ltd

(full implementation of the NDCM) and building C (did not fully implement the model) revealed that building A had 16 and 22 episodes and building C 25 and 64 episodes in 2005 and 2006, respectively. This study demonstrated that the role of the psychiatric APN could have a positive influence on the recovery of clients in a psychiatric hospital. Similarly, the integration of the practice of psychiatric APNs was introduced in the ED. Wand et al. (2011) adopted realistic evaluation as the methodology for the implementation and evaluation of an ED-based mental health nurse practitioner (MHNP) outpatient service. The survey involving 101 outpatients showed that for 66% of the outpatients, the mean score in K-10 measures decreased by two categories (P < 0.001) at follow-up and the mean score in the General Self Efficacy Scale improved by one point at follow-up, while an improvement was also seen in perceived self-efficacy (P = 0.0137). Client satisfaction tool (n = 51) showed strong agreement with the availability (n = 38, 74.5%) and accessibility of the service (n = 35, 68.6%); therapeutic features: support and encouragement received (n = 38, 74.5%); the feeling of being listened to and understood (n = 36, 70.6%); useful information and health education (n = 31, 60.8%); and overall standard of care provided (n = 35, 68.6%). The interview with 20 ED staff showed that this service assists patients whose needs are not usually met (to a considerable extent: 80%, to a moderate extent: 20%). It also showed that the straightforward referral process was greatly appreciated (70%, 30%); and that the outpatient service had improved and streamlined access to follow-up mental health care (70%, 30%); raised mental health awareness (60%, 35%); and enhanced the overall service provided by the ED (85%, 15%). This study also developed middle-range theories from the evaluation of the MHNP outpatient service and suggested that early consultation with key local stakeholders and ED ownership of the project was essential to the implementation process.

Provision of psychiatric nursing consultation services Five studies reported positive client outcomes from the collaborative service developed by a psychiatric APN and non-mental health service providers. Three studies involved clients with depression who were referred to a psychiatric APN by primary care nurses, NPs, or physicians (Beeber & Charlie 1998), or referred by an oncology APN for further psychiatric assessment and intervention (McCorkle et al. 2009, 2011). Two studies examined the psychiatric nursing consultation liaison (PNCL) services in a general hospital (Sharrock & Happell 2002, Johnston & Cowman 2008). These two studies revealed that the majority of patients were admitted to hospital because of a medical issue and that the most common reason for a PCLN referral was 711

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deliberate self-harm. In the study of Johnston & Cowman (2008), there was a significant difference between the diagnosis provided by the PCLN and the reason for the referral (Pearson chi-square = 36.89, d.f. = 16, P = 0.002). Four cases required the involvement of a psychiatrist; thus, 94% of the patients did not receive an assessment from a psychiatrist. This study showed that the PCLN operated as an autonomous practitioner and helped to meet the complex demands of the patients in a general hospital. In the study by Sharrock & Happell (2002), a survey of 117 staff using the PNCL services showed that >90% participants found these services to be timely, accessible, well documented, and professional. This study highlighted the positive contribution of the PCLN as perceived by general hospital staff.

Discussion The existing literature supports the view that psychiatric APNs play multifaceted roles and achieve significant results in managing clients with depression and psychological stress, and in improving inpatient services. Understanding the role performance of psychiatric APNs will help nurses to develop contemporary mental health-care services. The implications for research methods and for the development of psychiatric nursing services are discussed below.

Implications for research methods The 14 quantitative studies provided useful findings on the role performance of psychiatric APNs. However, only one study addressed the role of a psychiatric APN working in a general hospital (Wand et al. 2011). In addition, this systematic review can only provide preliminary and inconsistent evidence supporting the significance of psychiatric APNs’ role performance. Only a few significant randomized controlled trials reported modest outcomes, and a study by Price (2007) indeed revealed non-significant results in transitional care for pre-discharged patients with schizophrenia. Also, the outcome measurements varied greatly among the included studies; thus, it was difficult to compare them directly. It is recommended that standardized outcome measures be used when the studies involve similar types or models of intervention. In addition, those studies with innovative and advanced psychosocial interventions lacked comparison with other treatment modalities, or benchmarks with generic practices. When new services or alternative health-care options are provided, it is important to demonstrate their significance with evidence (Kirchhoff 1999). Therefore, well-designed, randomized controlled trials are needed to evaluate the role performances of psychiatric APNs. 712

Implications for the development of psychiatric nursing services The studies demonstrated that the psychiatric APN provides a wide-ranging service to individuals with mental health-care needs, and in user-friendly settings. Multiple included studies documented that individuals with mental health-care needs also had medical problems (Sharrock & Happell 2002, Johnston & Cowman 2008, Knight & Houseman 2008, McCorkle et al. 2009, 2011, Hanrahan et al. 2011, Wand et al. 2011). These findings were consistent with the study by Kisely & Goldberg (1996), who reported that people with a severe physical illness are more likely to develop a mental disorder. Therefore, it is suggested that partnering medical health-care providers with psychiatric APNs has the potential to improve advanced nursing services because the nursing roles can be deployed to meet the physical and mental health-care needs of the clients. In addition, the studies revealed that psychiatric APNs contributed to the detection and treatment of individuals with mental health-care needs in non-mental health-care settings. The provision of psychiatric assessments and interventions in non-mental healthcare settings addresses the stigma of mental illness (Johnston & Cowman 2008), and a domiciliary visit addresses the problem of accessibility for frail adults (Knight & Houseman 2008). Therefore, it is suggested that psychiatric APNs should develop on-site psychosocial interventions or services in the form of domiciliary visits that improves the accessibility of mental health-care services. In addition, the role of the psychiatric APN in private practice is an important finding that deserves attention. It is inevitable that independent psychiatric APNs will face market competition from other service providers. It is suggested that psychiatric APNs should be ready to provide an autonomous practice and demonstrate cost-effective psychiatric nursing interventions through well-designed studies. While the evidence to support the role performance of psychiatric APNs for psychiatric inpatients was inconclusive, there was evidence to support the implementation of a nurse-led service at the ward level (E-Morris et al. 2010). In the inpatient setting, nurses make up the greatest number of hospital staff, and they care for their patients throughout the day. Psychiatric APNs are in the best position to identify the mental health needs of patients and to provide high-quality services that can enhance their health-related outcomes. For example, an APN-led intervention could aim at facilitating the early discharge of patients, improving their adherence to medication, and enhancing symptom control with innovative psychosocial interventions. © 2013 John Wiley & Sons Ltd

Systematic review on role performance of psychiatric APN

Limitations This systematic review used only the results of previously published articles in English. The reviewed studies have different outcome measures and study designs; thus, it was not possible to conduct a meta-analysis. Great differences in the purposes and objectives of the 14 reviewed studies also made it difficult to evaluate the efficacy of the interventions and role performance of the psychiatric APNs. While the majority of the studies did not directly examine the role of the psychiatric APN, information to determine the role performance of psychiatric APNs was extracted based on the aims of the studies. This information may indirectly contribute to our knowledge of the performance of psychiatric APNs in relation to these roles. Due to our intention to reduce complexity and enhance objective and specific conclusions from the reviewed literature, qualitative studies were not included in this systematic review. This would lose the diversity of evidences and become unhelpful for answering the

complex questions about social roles and functions, as such among these psychiatric APNs, that confront the practitioners and policymakers. As there is limited good quality or ‘rigorous’ quantitative research articles available, an integrative literature review, including qualitative studies, should be conducted to further examine this topic and thus contribute to more comprehensive and in-depth understanding of the perceived roles and functions of psychiatric APNs.

Conclusion This study consolidated information of the role performance of psychiatric APNs found in the 14 articles, which indicated that the psychiatric APNs performed multifaceted roles in various settings. The information presented here will provide mental health-care professionals with some food for thought in developing psychiatric advanced nursing practices that will fit their local health-care contexts.

Crismani C. & Galletly C. (2011) ‘Walk-

References

ins’: developing a nursing role to manage

AMA (2010) Nursing: Scope and Standards of Practice, 2nd edn. American Nurses Associa-

(accessed 22 December 2010).

unscheduled presentations to a community

Johnston M.L. & Cowman S. (2008) An examina-

mental health clinic. Contemporary Nurse 39,

tion of the services provided by psychiatric con-

12–19.

sultation liaison nurses in a general hospital.

Downs S.H. & Black N. (1998) The feasibility of

tion, Silver Spring, MD.

publications/fact_sheets/1b_FS-NP_APN.pdf

Journal of Psychiatric and Mental Health Nursing 15, 500–507.

Baradell J.G. & Bordeaux B.R. (2001) Outcomes

creating a checklist for the assessment of the

and satisfaction of patients of psychiatric clini-

methodological quality both of randomized and

Kirchhoff K.T. (1999) Strategies in research utili-

cal nurse specialists. Journal of the American

non-randomized studies of health care interven-

zation, one form of evidence-based practice. In:

Psychiatric Nurses Association 7, 67–75.

tions. Journal of Epidemiology and Community

Using and Conducting Nursing Research in the

Health 52, 377–384.

Clinical Setting (eds Mateo, M.A. & Kirchhoff,

Beeber L.S. & Charlie M.L. (1998) Depressive symptom reversal for women in a primary care

E-Morris M., Caldwell B., Mencher K.J., et al.

setting: a pilot study. Archives of Psychiatric

(2010) Nurse-directed care model in a psychiat-

Nursing 11, 247–254.

ric hospital: a model for clinical accountability.

Beeber L.S., Cooper C., Van Noy B.E., et al. (2007)

K.T.), pp. 56–63. W. B. Saunders Company, Philadelphia, PA. Kisely S.R. & Goldberg D.P. (1996) Physical and psychiatric comorbidity in general practice. The

Clinical Nurse Specialist 24, 154–160.

Flying under the radar: engagement and reten-

Hanrahan N.P., Wu E., Kelly D., et al. (2011)

tion of depressed low-income mothers in a

Randomized clinical trial of the effectiveness of

Knight M.M. & Houseman E.A. (2008) A Col-

mental

a home-based advanced practice psychiatric

laborative model for the treatment of depression

nurse intervention: outcomes for individuals

in homebound elders. Issues in Mental Health

health

intervention.

Advances

in

Nursing Science 30, 221–234. Campbell C.D., Musil C.M. & Zauszniewski J.A. (1998) Practice patterns of advanced practice psychiatric nurses. Journal of the American Psychiatric Nurses Association 4, 111–120.

with serious mental illness and HIV. Nurse Research

and

Practice

2011,

1–10.

doi:

10.1155/2011/840248.

life outcomes in post-surgical women with gynecological cancers. Psycho-Oncology 18,

development: nurse practitioner and clinical

catastrophic stress. Issues in Mental Health

-practitioner-and-clinical-specialists

(accessed

24 December 2011). Cornwell C. & Chiverton P. (1997) The psychiatric

Effects of a nursing intervention on quality of

(2002) Effects of a long-term psychosocial nursing intervention on adolescents exposed to

.ca/en/perfectionnement-professionnel/nurse

Nursing 29, 974–991. McCorkle R., Dowd M., Ercolano E., et al. (2009)

Hardin S.B., Weinrich S., Weinrich M., et al.

Canadian Nurses Association (2013) Professional specialists. Available at: http://www.cna-aiic

British Journal of Psychiatry 169, 236–242.

Nursing 23, 537–551. International Council of Nurses (n.d.) Practice issues: definition and characteristics of the role. Available

at:

http://www.icn-apnetwork.org

(accessed 22 December 2010).

62–70. McCorkle R., Jeon S., Ercolano E., et al. (2011) Healthcare utilization in woman after abdominal surgery for ovarian cancer. Nursing Research 60, 47–57. McDougall G., Blixen C.E. & Suen L.J. (1997) The process and outcome of life review psycho-

advanced practice nurse with prescriptive

International Council of Nurses (2009) Nursing

authority: role development, practice issues, and

matters: nurse practitioner/advanced practice

outcomes measurement. Archives of Psychiatric

nurse: definition and characteristics. Available

Price L.M. (2007) Transition to community: a

Nursing 11, 57–65.

at: http://www.icn.ch/images/stories/documents/

program to help clients with schizophrenia

© 2013 John Wiley & Sons Ltd

therapy with depressed homebound older adults. Nursing Research 46, 277–283.

713

Y. L. Fung et al.

move from inpatient to community care; a pilot

Sheer B. & Wong F.K.Y. (2008) The development

Wand T., White K. & Patching J. (2011) Realistic

study. Archives of Psychiatric Nursing 21, 336–

of advanced nursing practice globally. Journal

evaluation of an emergency department-based

344.

of Nursing Scholarship 40, 204–211.

mental health nurse practitioner outpatient service in Australia. Nursing and Health Sci-

Psychiatric Mental Health Nursing Scope and

Wand T., White K. & Patching J. (2010a) Applying

Standards (2006) Psychiatric mental health

a realist(ic) framework to the evaluation of a

nursing scope draft revision 2006. Available at:

new model of emergency department based

Wheeler K. & Haber J. (2004) Development of

http://www.ispn-psych.org/docs/standards/

mental health nursing practice. Nursing Inquiry

psychiatric-mental health nurse practitioner

scope-standards-draft.pdf (accessed 24 Decem-

17, 231–239.

competencies:

ber 2010). Sharrock J. & Happell B. (2002) The psychiatric

Wand T., White K., Patching J., et al. (2010b) Introducing

a

new

model

of

emergency

consultation-liaison nurse: thriving in a general

department-based mental health care. Nurse

hospital setting. International Journal of Mental

Researcher 18, 35–43.

ences 13, 199–206.

opportunities

for

the

21st

century. Journal of the American Psychiatric Nurses Association 10, 129–138.

Health Nursing 11, 24–33.

714

© 2013 John Wiley & Sons Ltd