SubspecializationWithinPsychiatric Consultation-LiaisonNursing Lauren B. Moschler and Joy Fincannon
Specialization within health care is evoking in response to the proliferation of knowledge about disease treatment and health management. The practice of psychiatric consultation-liaison nursing in the acute care hospital is diversifying through subspeciafiiation as a result of thii trend. This article examines the concept of subspecialiiation within psychiatric consultation-liaison nursing practice. Subspecialization is presented as a safeguard for professional viability and as a hallmark of quality consumer care. Specialization has advantages and potential disadvantages for nursing practice. Strategies are described that maximize the benefits and minimize the disadvantages of subspecialiiation. Copyright 0 1992 by W.B. Saunders Company
S
INCE THE CREATION of psychiatric consultation-liaison nursing (PCLN) in the 196Os, the PCLN role has evolved and diversified. In recent years, coinciding with the movement of specialization within health care, a phenomenon of subspecialization within PCLN has begun to emerge in collaboration with generalist PCLN practice. SUBSPECIALIZATION:
DEFINITION AND
KEY DILEMMAS
The psychiatric consultation-liaison nurse who subspecializes maintains a core identity with a master’s degree in psychiatric mental-health nursing. According to the American Nurses Association’s (ANA; 1990) standards of PCLN practice, psychiatric consultation-liaison nurses (PCLNs) are involved in direct care of clients/families and have consultative, collaborative, and educative relationships with nurses and other health care providers. In this role, they “. . . (1) influence and
From the Neurosciences Nursing Department, The Johns Hopkins Hospital; and the Oncology Nursing Department, The Johns Hopkins Oncology Center, Baltimore, MD. Address reprint requests to Lauren B. Moschler, M.S., R.N.. C.S.. Psuchiatric Consultation-Liaison Nurse, Neurosciences Nuking, Meyer3-122, 600 N Wolfe St Baltimore, MD 21205. Copyright 0 I992 by W.B. Saunders Company 08t33-9417/92iO604-0007$3.00~0
234
enhance their knowledge of and skill in addressing the biopsychosocial aspects of the care of clients/ families, and (2) promote their capacity to function optimally in the practice setting” (p. 1). In addition to this generalist practice, the PCLN subspecialist has extensive experience and/or formal certification in a generic, defined medical/surgical nursing specialty area. For instance, the PCLN with another area of specialty knowledge, such as oncology nursing, has a different knowledge base than a PCLN with a neurosciences nursing background. Figure 1 illustrates this definition further. Figure 1 depicts the specialization trend as one progresses from becoming a generic nurse to a PCLN. The subspecialist PCLN began the career path as a medical/surgical nurse before pursuing psychiatric nursing. The subspecialist PCLN combines medical/surgical knowledge with psychiatric mental-health and consultation-liaison training. Although subspecialty evolution in psychiatric and mental-health nursing has been recently examined (Murphy & Heoffer, 1987; McBride, 1990), the phenomenon of subspecialization within PCLN has not been described in the literature. Several important questions arise in the authors’ minds: Does this concept reflect overspecialization within the nursing profession? How does subspecialization of PCLN conform within the whole of nursing as it strives to unify a vast array of specialties? Styles (1989) defines empowerment in nursing as “unity, homogeneity, and legitimacy” (p. 19). Is
Archives of Psychiatric Nursing, Vol. Vl, No. 4 (August), 1992: pp. 234-238
235
SUBSPECIALIZATION
TOP
Oncology Nursing
Fig 1. The definition illustrated.
of subspecialization
within PCLN is
subspecialization within the PCLN specialty a means to or a hinderance to empowerment? Does subspecialization impact generalist PCLN practice with knowledge and theory development? Should the concept of subspecialization be formally recognized and cultivated within PCLN practice? This article examines and addresses these notable questions. HISTORICAL DEVELOPMENT
As posited by Robinson (1986), “It is indubitably true that the seeds of the future are sown in the present, and the directions of their growth and development derive from the past” (p. 537). Specialization is an evolutionary trend. The following are historical points of relevancy about consultationliaison psychiatry. Medicine began to branch into specialties in the 1940s and 1950s as a response to the proliferation of knowledge and technology. The concept of consultation-liaison medicine was formally introduced in 1929 by Henry from Cornell Medical School. He envisioned a hospital-based psychiatrist available for consultation to other physicians. The Lowell Report of 1932 was a summary of the work accomplished by the Commission on Medical Education. This report emphasized the importance of integrating psychiatric teaching into the curricula of general medicine, pediatrics, and neurology (Lipowski, 1974). This conceptualization occurred in tandem with the development of psychosomatic medicine. In the 193Os, consultation-liaison psychiatry emerged as a subspecialty with funding from the Rockefeller Foundation. The funding established five psychiatric liaison departments within general hospitals.
Consultation-liaison psychiatry emerged from psychiatric nursing in the 1960s. In 1963, Johnson was the first to describe a nursing consultation service at Duke University Medical Center. By the early 1970s the University of Maryland and Yale University formally integrated training for PCLN within their graduate programs. Nursing roles were created to bridge the gap between psychiatric and medical/surgical nursing care in hospitals (Nelson & Schilke, 1976, p. 63). Lipowski (1972) alluded to the need for dually specialized knowledge. He wrote, “Every specialty presents the psychiatric consultant with diagnosis and management problems that are in some respects unique” (p. 365). There is evidence today of consultation-liaison psychiatry becoming further specialized. A pain treatment unit is an example of such specialization. The psychiatry team uses medical knowledge in conjunction with mental-health knowledge to treat pain. The diversity within consultation-liaison practice continues to evolve. The following sections describe the advantages of subspecialization and then outline the potential disadvantages of subspecialization within PCLN. Strategies for minimizing each disadvantage are offered. ADVANTAGES
OF SUl3SPEClALlZATlON
Greater Marketability
The focus of the PCLN role is on the “emotional, spiritual, developmental, cognitive, and behavioral responses of clients/families who enter the health care system with actual or potential physical dysfunction” (ANA, 1990, p. 1). In today’s consumer climate, patients and families expect care from the most knowledgeable health professionals. Specialty implies this knowledge. The health care practitioner must tailor products to not only the consumer’s interest, but also to the consumer’s need. One tool that enhances marketability is the subspecialist’s knowledge of community resources for a specific patient population. Sharing the variety of resources with patients and families meets a critical need. Certification within a generic nursing specialty validates experiential practice. Furthermore, marketability also increases when combining two specialties, such as neurosciences and psychiatric nursing. Entry into other areas of specialty, as with
236
MOSCHLER AND FINCANNON
the subspecialist PCLN role, promotes the visibility of the psychiatric consultation-liaison concept. Improved Consultant-Consultee
Relationships
The consultee and the subspecialist PCLN share a common language. Additionally, the participantobserver experience of the subspecialist PCLN adds value to the role as the daily routine, dilemmas, and stressors are recalled from the first person perspective. For instance, nurses caring for amyotrophic lateral sclerosis patients are benefited by the neuroscience PCLN who readily identifies with the feelings evoked when caring for these patients. The unusual sight of disease and treatment results that often shock other consultants are familiar to the PCLN who has previously worked with such patients as a clinical nurse. Clinical nurses who care for these uniquely challenging patients must process their experiences to enhance their therapeutic psychological work with patients. Examples provided from personal experience add credibility as the PCLN assists the consultees to achieve such an outcome. Physician consultees who assume that PCLNs “hold patient’s hands” are apt to dispel this misconception when it is obvious that the medical intricacies are understood by the subspecialist
PCLN . Familiarity with ethical dilemmas, particularly within one’s generic specialty, helps the PCLN to identify and assist consultees appropriately. For example, the goal of adequate pain management in oncology nursing is sometimes complicated by the possibility of respiratory depression. Proactive discussion of these ethically complicated situations aids their resolution. The recommendations made by the subspecialist PCLN add specificity. The neurosciences PCLN, for instance, uses knowledge of the specialty to enhance the nurse’s comfort after a postoperative patient with an arteriovenous malformation resection unexpectedly dies. Reviewing the chronology of events, the PCLN’s use of neurosurgery knowledge helps the staff alleviate their guilt and more appropriately grieve. Ejjkient and Expert Patient Care
Perhaps the most important advantage of subspecialization is expert and efficient patient care. With focused practice, the PCLN evaluates a patient and recommends interventions efficiently.
Care is individualized and made safer by understanding the disease, treatment modalities, care setting, and the patient population. Detection of preventable clinical dilemmas is enhanced. Indeed, subspecialization proves logical in this era of exponential growth of medical and nursing knowledge. An example illustrates these assertions: The oncology PCLN is periodically consulted to evaluate suicidal ideation. The assessment of a 50year-old patient with leukemia includes recognition that it is common for an oncology patient to passively desire death. PCLN Satisfaction
The degree of personal and professional satisfaction achieved with subspecialization is enhanced by focusing practice in one’s area of interest. Subspecialization also tends to attract both achievement-oriented professionals and those who desire working with a focused patient population. This narrowing of focus is positive when educational and research projects are cultivated by a multidisciplinary approach. Research is further enhanced by familiarity with instrumentation commonly used within one’s generic specialty. The publication arena is broadened when practicing two specialties. In addition, there is satisfaction within the role because even the subspecialist PCLN is used for a variety of needs, preventing a myopic perspective. Holistic Approach
One of the historically recognized problems in psychiatric nursing is the schism between the mind and the body. With subspecialization, this gap is narrowed. intuitive nursing care is de-emphasized by focusing on the interaction between biological and psychological aspects of an illness. Concurrently, the subspecialist PCLN can focus on keeping abreast of specific medication interaction knowledge that improves one’s understanding of physiological symptoms and their impact on mental health. For example, the effective dosage of tricyclic antidepressants for oncology patients is lower than that for the psychiatrically ill population (Massie & Holland, 1987). DISADVANTAGES
OF SUBSPECIALIZATION
Although the advantages of subspecialization are many, as previously described, the potential disadvantages of subspecialization are apparent to
237
SUBSPECIALIZATION
the authors who believe these must be recognized and minimized. Each disadvantage is examined and strategies for minimizing each disadvantage are discussed.
survival. For example, the National Board of Nursing Specialties contributes to unity by reviewing and approving specialties and their standards and by processing certification and accreditation.
Limitations
Split Identity Dilemmas
on Practice
Focusing on a specific patient population can breed fragmentation of care. Indeed, one must be wary of becoming overspecialized. Welch (1987) warns about not specializing in a narrow area that could become obsolete. For example, what is the fate of the renal clinical nurse specialist when the artificial kidney becomes perfected? Maintaining a knowledge base by reading and continuing education in both areas of specialty might prevent overspecialization. To decrease the subspecialist’s sense of isolation, consultation among PCLNs is encouraged. Focusing on interspecialty nursing research further diminishes isolation through collaboration and yields more generalizable results because a broader sample size is typically used. DisunityiConjlict
The authors speculate that subspecialist PCLNs can be perceived as competing with generalist PCLNs. Subspecialization does not infer superiority over generalist PCLN practice. Strategies to encourage collaboration include (1) avoid competition by focusing energies positively on common bonds including the core knowledge base shared from theories such as general systems, crisis intervention, and psychiatric nursing; (2) conduct intraspecialty research among PCLNs to avoid duplication of effort; (3) avoid new language and maintain documentation consistent with generalist PCLN practice; (4) classify data in concordance with generalist and subspecialist PCLN standards; (5) practice within established frameworks of training, accreditation, and American Nurses Association standards. The newly updated nursing standards for practice are reflective of specialty practice (Styles. 1989); and (6) become aware of efforts to strengthen specialty organizations so that networking between these groups is promoted. Until recently, as noted by Boss (1989), nursing’s past with specialization has been characterized by diffusion, variability, and undefined boundaries. It is imperative to recognize the importance of specialty organizations so that a healthy federation of subspecialties is enhanced. This strengthens unity yet preserves diversity and
The PCLN may become confused about professional identity and whether allegiance is owed to the psychiatric or the medical nursing specialty area. Focusing on applying the principles and practices of psychiatric nursing within one’s generic nursing specialty through individual professional continuing education and research endeavors reinforces one’s professional identity. Visibility as a psychiatric mental-health clinical nurse specialist is reinforced in the context of one’s generic specialty organization by introducing oneself at meetings when presenting, and when publishing, as a psychiatric mental-health clinical nurse specialist. Survival Realities
Economic realities of our time are inescapable. Large university-based and decentralized institutions create a climate ripe for specialty growth. These centers are more apt than other hospital centers to have subspecialization possibilities. To maximize the opportunities for subspecialist PCLN positions while supporting the whole of PCLN practice, the following strategies are recommended: (1) to avoid competition, as fee for service becomes more customary within hospitals, the fees charged for generalist PCLN services should approximate fees charged for subspecialist PCLN services; and (2) take advantage of interdisciplinary research efforts because funding sources will be more abundant. FUTURE RECOMMENDATIONS
The preceding recommendations can be instituted without delay. However, in the future, as subspecialist PCLNs become more prevalent, incorporating such roles into university PCLN curricula will add vigor and specificity to academic training. Furthermore, it is necessary for aspiring subspecialists to obtain a minimum of 1 or 2 years of experiential training within the generic nursing specialty. Certification in this specialty is highly recommended by the authors. SUMMARY
This article explores the concept of subspecialization within PCLN practice in the context of con-
230
MOSCHLER AND FINCANNON
sultation-liaison nursing. Subspecialization is an evolutionary trend that not only maximizes safe and effective care but also promotes higher levels of satisfaction for some PCLNs. Psychiatric nursing leaders of our specialty have defined the task for psychiatric nurses in the decade of the 1990s as achieving “differentiation and balance” (Pothier, Stuart, Puskar & Babich, 1990). Subspecialization within PCLN typifies this pursuit. REFERENCES American Nurses Association. (1990). Standards ofpsychiatric consulration-liaison nursing practice. Kansas City, MO: Author. Boss, B.J. (1989). Presidential address: Specialty nursing. The Journal of Neuroscience Nursing, 21(4), 213-215. Lipowski, Z.J. (1972). Psychiatric liaison neurology and neurosurgery. American Journal of Psychiatry, 129(2), 136-140.
Lipowski, Z.J. (1974). Consultation-liaison psychiatry: An overview. American Journal of Psychiatry, 131(6), 623-630.
Massie, M.J., &Holland, J.C. (1987). Consultation and liaison issues in cancer care. Psychiatric Medicine, 5(4), 343359.
McBride, A.B. (1990). Psychiatric nursing in the 1990’s. Archives of Psychiatric Nursing, 5(4), 343-359.
Murphy, S.A., & Heoffer, B. (1987). The evolution of subspecialties in psychiatric and mental health nursing. Archives of Psychiatric Nursing, l(3). 145-154.
Nelson, J.K., & Schilke, D.A. (1976). The evolution of psychiatric liaison nursing. Perspectives of Psychiatric Care, 14(2), 60-65.
Pothier, P.C., Stuart, G. W., Puskar, K., & Babich, K. (1990). Dilemmas and directions for psychiatric nursing in the 1990’s. Archives ofPsychia?ric Nursing, 4(5), 284-291. Robinson, L. (1986). The future of psychiatric/mental health nursing. Nursing Clinics of North America, 21(3), 537543.
Styles, M.M. (1989). On speciulizarion in nursing: Toward a new empowerment. Kansas City, MO: American Nurses’ Foundation. Welch, CC. (1987). A window of opportunity. Nursing Ourtook, 3X6), 282-284.
Specialization within health care is evoking in response to the proliferation of knowledge about disease treatment and health management. The practice of psychiatric consultation-liaison nursing in the acute care hospital is diversifying through subspeciafiiation as a result of thii trend. This article examines the concept of subspecialiiation within psychiatric consultation-liaison nursing practice. Subspecialization is presented as a safeguard for professional viability and as a hallmark of quality consumer care. Specialization has advantages and potential disadvantages for nursing practice. Strategies are described that maximize the benefits and minimize the disadvantages of subspecialiiation. Copyright 0 1992 by W.B. Saunders Company
S
INCE THE CREATION of psychiatric consultation-liaison nursing (PCLN) in the 196Os, the PCLN role has evolved and diversified. In recent years, coinciding with the movement of specialization within health care, a phenomenon of subspecialization within PCLN has begun to emerge in collaboration with generalist PCLN practice. SUBSPECIALIZATION:
DEFINITION AND
KEY DILEMMAS
The psychiatric consultation-liaison nurse who subspecializes maintains a core identity with a master’s degree in psychiatric mental-health nursing. According to the American Nurses Association’s (ANA; 1990) standards of PCLN practice, psychiatric consultation-liaison nurses (PCLNs) are involved in direct care of clients/families and have consultative, collaborative, and educative relationships with nurses and other health care providers. In this role, they “. . . (1) influence and
From the Neurosciences Nursing Department, The Johns Hopkins Hospital; and the Oncology Nursing Department, The Johns Hopkins Oncology Center, Baltimore, MD. Address reprint requests to Lauren B. Moschler, M.S., R.N.. C.S.. Psuchiatric Consultation-Liaison Nurse, Neurosciences Nuking, Meyer3-122, 600 N Wolfe St Baltimore, MD 21205. Copyright 0 I992 by W.B. Saunders Company 08t33-9417/92iO604-0007$3.00~0
234
enhance their knowledge of and skill in addressing the biopsychosocial aspects of the care of clients/ families, and (2) promote their capacity to function optimally in the practice setting” (p. 1). In addition to this generalist practice, the PCLN subspecialist has extensive experience and/or formal certification in a generic, defined medical/surgical nursing specialty area. For instance, the PCLN with another area of specialty knowledge, such as oncology nursing, has a different knowledge base than a PCLN with a neurosciences nursing background. Figure 1 illustrates this definition further. Figure 1 depicts the specialization trend as one progresses from becoming a generic nurse to a PCLN. The subspecialist PCLN began the career path as a medical/surgical nurse before pursuing psychiatric nursing. The subspecialist PCLN combines medical/surgical knowledge with psychiatric mental-health and consultation-liaison training. Although subspecialty evolution in psychiatric and mental-health nursing has been recently examined (Murphy & Heoffer, 1987; McBride, 1990), the phenomenon of subspecialization within PCLN has not been described in the literature. Several important questions arise in the authors’ minds: Does this concept reflect overspecialization within the nursing profession? How does subspecialization of PCLN conform within the whole of nursing as it strives to unify a vast array of specialties? Styles (1989) defines empowerment in nursing as “unity, homogeneity, and legitimacy” (p. 19). Is
Archives of Psychiatric Nursing, Vol. Vl, No. 4 (August), 1992: pp. 234-238
235
SUBSPECIALIZATION
TOP
Oncology Nursing
Fig 1. The definition illustrated.
of subspecialization
within PCLN is
subspecialization within the PCLN specialty a means to or a hinderance to empowerment? Does subspecialization impact generalist PCLN practice with knowledge and theory development? Should the concept of subspecialization be formally recognized and cultivated within PCLN practice? This article examines and addresses these notable questions. HISTORICAL DEVELOPMENT
As posited by Robinson (1986), “It is indubitably true that the seeds of the future are sown in the present, and the directions of their growth and development derive from the past” (p. 537). Specialization is an evolutionary trend. The following are historical points of relevancy about consultationliaison psychiatry. Medicine began to branch into specialties in the 1940s and 1950s as a response to the proliferation of knowledge and technology. The concept of consultation-liaison medicine was formally introduced in 1929 by Henry from Cornell Medical School. He envisioned a hospital-based psychiatrist available for consultation to other physicians. The Lowell Report of 1932 was a summary of the work accomplished by the Commission on Medical Education. This report emphasized the importance of integrating psychiatric teaching into the curricula of general medicine, pediatrics, and neurology (Lipowski, 1974). This conceptualization occurred in tandem with the development of psychosomatic medicine. In the 193Os, consultation-liaison psychiatry emerged as a subspecialty with funding from the Rockefeller Foundation. The funding established five psychiatric liaison departments within general hospitals.
Consultation-liaison psychiatry emerged from psychiatric nursing in the 1960s. In 1963, Johnson was the first to describe a nursing consultation service at Duke University Medical Center. By the early 1970s the University of Maryland and Yale University formally integrated training for PCLN within their graduate programs. Nursing roles were created to bridge the gap between psychiatric and medical/surgical nursing care in hospitals (Nelson & Schilke, 1976, p. 63). Lipowski (1972) alluded to the need for dually specialized knowledge. He wrote, “Every specialty presents the psychiatric consultant with diagnosis and management problems that are in some respects unique” (p. 365). There is evidence today of consultation-liaison psychiatry becoming further specialized. A pain treatment unit is an example of such specialization. The psychiatry team uses medical knowledge in conjunction with mental-health knowledge to treat pain. The diversity within consultation-liaison practice continues to evolve. The following sections describe the advantages of subspecialization and then outline the potential disadvantages of subspecialization within PCLN. Strategies for minimizing each disadvantage are offered. ADVANTAGES
OF SUl3SPEClALlZATlON
Greater Marketability
The focus of the PCLN role is on the “emotional, spiritual, developmental, cognitive, and behavioral responses of clients/families who enter the health care system with actual or potential physical dysfunction” (ANA, 1990, p. 1). In today’s consumer climate, patients and families expect care from the most knowledgeable health professionals. Specialty implies this knowledge. The health care practitioner must tailor products to not only the consumer’s interest, but also to the consumer’s need. One tool that enhances marketability is the subspecialist’s knowledge of community resources for a specific patient population. Sharing the variety of resources with patients and families meets a critical need. Certification within a generic nursing specialty validates experiential practice. Furthermore, marketability also increases when combining two specialties, such as neurosciences and psychiatric nursing. Entry into other areas of specialty, as with
236
MOSCHLER AND FINCANNON
the subspecialist PCLN role, promotes the visibility of the psychiatric consultation-liaison concept. Improved Consultant-Consultee
Relationships
The consultee and the subspecialist PCLN share a common language. Additionally, the participantobserver experience of the subspecialist PCLN adds value to the role as the daily routine, dilemmas, and stressors are recalled from the first person perspective. For instance, nurses caring for amyotrophic lateral sclerosis patients are benefited by the neuroscience PCLN who readily identifies with the feelings evoked when caring for these patients. The unusual sight of disease and treatment results that often shock other consultants are familiar to the PCLN who has previously worked with such patients as a clinical nurse. Clinical nurses who care for these uniquely challenging patients must process their experiences to enhance their therapeutic psychological work with patients. Examples provided from personal experience add credibility as the PCLN assists the consultees to achieve such an outcome. Physician consultees who assume that PCLNs “hold patient’s hands” are apt to dispel this misconception when it is obvious that the medical intricacies are understood by the subspecialist
PCLN . Familiarity with ethical dilemmas, particularly within one’s generic specialty, helps the PCLN to identify and assist consultees appropriately. For example, the goal of adequate pain management in oncology nursing is sometimes complicated by the possibility of respiratory depression. Proactive discussion of these ethically complicated situations aids their resolution. The recommendations made by the subspecialist PCLN add specificity. The neurosciences PCLN, for instance, uses knowledge of the specialty to enhance the nurse’s comfort after a postoperative patient with an arteriovenous malformation resection unexpectedly dies. Reviewing the chronology of events, the PCLN’s use of neurosurgery knowledge helps the staff alleviate their guilt and more appropriately grieve. Ejjkient and Expert Patient Care
Perhaps the most important advantage of subspecialization is expert and efficient patient care. With focused practice, the PCLN evaluates a patient and recommends interventions efficiently.
Care is individualized and made safer by understanding the disease, treatment modalities, care setting, and the patient population. Detection of preventable clinical dilemmas is enhanced. Indeed, subspecialization proves logical in this era of exponential growth of medical and nursing knowledge. An example illustrates these assertions: The oncology PCLN is periodically consulted to evaluate suicidal ideation. The assessment of a 50year-old patient with leukemia includes recognition that it is common for an oncology patient to passively desire death. PCLN Satisfaction
The degree of personal and professional satisfaction achieved with subspecialization is enhanced by focusing practice in one’s area of interest. Subspecialization also tends to attract both achievement-oriented professionals and those who desire working with a focused patient population. This narrowing of focus is positive when educational and research projects are cultivated by a multidisciplinary approach. Research is further enhanced by familiarity with instrumentation commonly used within one’s generic specialty. The publication arena is broadened when practicing two specialties. In addition, there is satisfaction within the role because even the subspecialist PCLN is used for a variety of needs, preventing a myopic perspective. Holistic Approach
One of the historically recognized problems in psychiatric nursing is the schism between the mind and the body. With subspecialization, this gap is narrowed. intuitive nursing care is de-emphasized by focusing on the interaction between biological and psychological aspects of an illness. Concurrently, the subspecialist PCLN can focus on keeping abreast of specific medication interaction knowledge that improves one’s understanding of physiological symptoms and their impact on mental health. For example, the effective dosage of tricyclic antidepressants for oncology patients is lower than that for the psychiatrically ill population (Massie & Holland, 1987). DISADVANTAGES
OF SUBSPECIALIZATION
Although the advantages of subspecialization are many, as previously described, the potential disadvantages of subspecialization are apparent to
237
SUBSPECIALIZATION
the authors who believe these must be recognized and minimized. Each disadvantage is examined and strategies for minimizing each disadvantage are discussed.
survival. For example, the National Board of Nursing Specialties contributes to unity by reviewing and approving specialties and their standards and by processing certification and accreditation.
Limitations
Split Identity Dilemmas
on Practice
Focusing on a specific patient population can breed fragmentation of care. Indeed, one must be wary of becoming overspecialized. Welch (1987) warns about not specializing in a narrow area that could become obsolete. For example, what is the fate of the renal clinical nurse specialist when the artificial kidney becomes perfected? Maintaining a knowledge base by reading and continuing education in both areas of specialty might prevent overspecialization. To decrease the subspecialist’s sense of isolation, consultation among PCLNs is encouraged. Focusing on interspecialty nursing research further diminishes isolation through collaboration and yields more generalizable results because a broader sample size is typically used. DisunityiConjlict
The authors speculate that subspecialist PCLNs can be perceived as competing with generalist PCLNs. Subspecialization does not infer superiority over generalist PCLN practice. Strategies to encourage collaboration include (1) avoid competition by focusing energies positively on common bonds including the core knowledge base shared from theories such as general systems, crisis intervention, and psychiatric nursing; (2) conduct intraspecialty research among PCLNs to avoid duplication of effort; (3) avoid new language and maintain documentation consistent with generalist PCLN practice; (4) classify data in concordance with generalist and subspecialist PCLN standards; (5) practice within established frameworks of training, accreditation, and American Nurses Association standards. The newly updated nursing standards for practice are reflective of specialty practice (Styles. 1989); and (6) become aware of efforts to strengthen specialty organizations so that networking between these groups is promoted. Until recently, as noted by Boss (1989), nursing’s past with specialization has been characterized by diffusion, variability, and undefined boundaries. It is imperative to recognize the importance of specialty organizations so that a healthy federation of subspecialties is enhanced. This strengthens unity yet preserves diversity and
The PCLN may become confused about professional identity and whether allegiance is owed to the psychiatric or the medical nursing specialty area. Focusing on applying the principles and practices of psychiatric nursing within one’s generic nursing specialty through individual professional continuing education and research endeavors reinforces one’s professional identity. Visibility as a psychiatric mental-health clinical nurse specialist is reinforced in the context of one’s generic specialty organization by introducing oneself at meetings when presenting, and when publishing, as a psychiatric mental-health clinical nurse specialist. Survival Realities
Economic realities of our time are inescapable. Large university-based and decentralized institutions create a climate ripe for specialty growth. These centers are more apt than other hospital centers to have subspecialization possibilities. To maximize the opportunities for subspecialist PCLN positions while supporting the whole of PCLN practice, the following strategies are recommended: (1) to avoid competition, as fee for service becomes more customary within hospitals, the fees charged for generalist PCLN services should approximate fees charged for subspecialist PCLN services; and (2) take advantage of interdisciplinary research efforts because funding sources will be more abundant. FUTURE RECOMMENDATIONS
The preceding recommendations can be instituted without delay. However, in the future, as subspecialist PCLNs become more prevalent, incorporating such roles into university PCLN curricula will add vigor and specificity to academic training. Furthermore, it is necessary for aspiring subspecialists to obtain a minimum of 1 or 2 years of experiential training within the generic nursing specialty. Certification in this specialty is highly recommended by the authors. SUMMARY
This article explores the concept of subspecialization within PCLN practice in the context of con-
230
MOSCHLER AND FINCANNON
sultation-liaison nursing. Subspecialization is an evolutionary trend that not only maximizes safe and effective care but also promotes higher levels of satisfaction for some PCLNs. Psychiatric nursing leaders of our specialty have defined the task for psychiatric nurses in the decade of the 1990s as achieving “differentiation and balance” (Pothier, Stuart, Puskar & Babich, 1990). Subspecialization within PCLN typifies this pursuit. REFERENCES American Nurses Association. (1990). Standards ofpsychiatric consulration-liaison nursing practice. Kansas City, MO: Author. Boss, B.J. (1989). Presidential address: Specialty nursing. The Journal of Neuroscience Nursing, 21(4), 213-215. Lipowski, Z.J. (1972). Psychiatric liaison neurology and neurosurgery. American Journal of Psychiatry, 129(2), 136-140.
Lipowski, Z.J. (1974). Consultation-liaison psychiatry: An overview. American Journal of Psychiatry, 131(6), 623-630.
Massie, M.J., &Holland, J.C. (1987). Consultation and liaison issues in cancer care. Psychiatric Medicine, 5(4), 343359.
McBride, A.B. (1990). Psychiatric nursing in the 1990’s. Archives of Psychiatric Nursing, 5(4), 343-359.
Murphy, S.A., & Heoffer, B. (1987). The evolution of subspecialties in psychiatric and mental health nursing. Archives of Psychiatric Nursing, l(3). 145-154.
Nelson, J.K., & Schilke, D.A. (1976). The evolution of psychiatric liaison nursing. Perspectives of Psychiatric Care, 14(2), 60-65.
Pothier, P.C., Stuart, G. W., Puskar, K., & Babich, K. (1990). Dilemmas and directions for psychiatric nursing in the 1990’s. Archives ofPsychia?ric Nursing, 4(5), 284-291. Robinson, L. (1986). The future of psychiatric/mental health nursing. Nursing Clinics of North America, 21(3), 537543.
Styles, M.M. (1989). On speciulizarion in nursing: Toward a new empowerment. Kansas City, MO: American Nurses’ Foundation. Welch, CC. (1987). A window of opportunity. Nursing Ourtook, 3X6), 282-284.
