COVID-19

It would be difficult to talk about the early 2020s without detailing some of the social and economic disruptions of the COVID-19 world-wide pandemic: the required masks and gloves; the encouragement to stay home, to avoid crowds or any social gathering, including with extended family or at church or in schools; the prolonged isolation, maintaining six feet distance from others if in a grocery store, a business, even on the sidewalk; the closure of businesses; the loss of income and jobs; the quarantines of anyone testing positive for the virus or living with them; and the vaccines for health professionals as well as the general public. There were so many unknowns.

The impact on health and the healthcare system was also dramatic. Hospitalizations of people with COVID-19 were numerous. Desperately ill patients arrived at medical facilities, packed hospitals, and stressed healthcare providers, not just with the workload but with the many deaths that occurred. As the country struggled to understand this frightening new and extraordinarily contagious illness and how to adjust their lives, healthcare was stretched to a breaking point in many cities in our nation and in countries around the world.

Educational systems, from elementary and high schools to colleges and universities, were among the first to use technology to attempt new strategies to continue their work. Because of the pandemic, nearly all the University of Utah didactic courses were being taught remotely, and faculty needed to learn new teaching methods if they wanted to be effective teachers. Computer teaching techniques included online pictures and textbooks, recorded lectures, and live face-to-face lectures via zoom and other video platforms. Some faculty adapted well; others found it difficult. The College of Nursing faculty transitioned relatively quickly and well for the academic courses. The Psychiatric-Mental Health Nursing Faculty had, of course, been offering distance learning courses to rural areas for almost 25 years before the pandemic. And the online doctoral program for Oncology nurses had provided some faculty in other disciplines with learning experience with this form of instruction. This doctoral program, started by Kathi Mooney, had lasted for 14 years but had stopped by the time of the pandemic.

Among the COVID restrictions, the most serious problem for educating nurses came from the limitations on clinical teaching. Students were welcome, even needed, but some settings simply did not have enough masks or shields or gloves for their staff, let alone students. Of necessity, some adjustments of required time in clinicals were made. But there was such a shortage of nurses that students could work part-time and assist with vaccine administration all over the state. Also, faculty were resourceful and with some adjustments were able to provide excellent learning experiences for students.

Faculty and staff, as well as nurses and all other hospital staff, were justifiably fearful of bringing home the COVID-19 virus to their families. Finding ways to care for the sick was a priority but so was protecting one’s family from the virus. With these two conflicting priorities, nurses were challenged with personal ethical dilemmas.

After the initial fears abated somewhat and safety measures were adopted, the University carried on its work. Meetings may have been held less often and usually via teleconferencing but teaching across campus continued. Even as the pandemic steamrolled ahead with new COVID mutations surfacing and science scrambling to develop new vaccines, people adapted. Masks were still required in the Health Sciences Colleges, Health Science Library, and the hospital and clinics through 2022. By the beginning of 2023, masks were still encouraged within the Health Sciences, but not required, except in the hospital and clinics where patients were at risk and libraries where students congregated.

Theories

New theories of mental health continued to develop, usually building on previous theories. There was a strong emphasis on diagnosing mental illness according to DSM-5-TR, with ever more attention on documenting treatment outcomes. As has been noted, these proofs of treatment efficacy are demanded by insurance companies to justify reimbursement for Mental Health services. While there were some research efforts to study efficacy of treatment, most research monies from NIH went to study genetics and mental health or efficacy of medication management of severe mental illnesses.

National Issues

Mental health issues, both AMI and SMI (Any Mental Illness and Severe Mental Illness), gained greater attention in the media. The isolation and stresses of the pandemic seemed to exacerbate symptoms of mental illness. There was greater demand for medications and for therapy, with special emphasis on children and the negative impact of restrictions on their education and social lives. There were not enough mental health professionals to meet these increased demands, nor were there enough nurses to meet the greater demand for additional nurses in hospitals, primary care settings, and emergency rooms. Increases of drug abuse, homelessness, and suicide were frequently headlined and discussed in the news, especially as they related to access for mental health services.

Leadership and Curriculum

Currently, Dr. Marla DeJong is the Dean of the College of Nursing and Dr. Sheila Deyette is director of the graduate Psychiatric-Mental Health Nursing track of the DNP Program. Regular faculty teaching in the track included: Sheila Deyette, Elois Bailey, and Ann Hutton. (Ann has now retired after 54 years teaching at the University of Utah, mostly in the graduate psychiatric nursing program.)

Curriculum and Faculty. The Psychiatric-Mental Health-DNP track remains much the same as in previous years with two notable additions. A genetics course and a course in Health Care Financing have been added to the curriculum. The Psychiatric-Mental Health DNP requires 86 credits and is a year-round program if the student is attending full time. The program can be completed in 8 semesters. The current course curriculum can be found in Appendix II.

In addition, there are 6 semesters of clinical practicums, which includes at least 1200 clinical hours. Clinical placements are in both public and private behavioral healthcare settings in the greater Salt Lake Valley area, northern, mid-, and southern Utah. Three of the six semester practicums focus on clinical interviewing and foundational psychotherapy skills, and the other three focus on comprehensive psychiatric assessment and prescriptive practice.

All faculty at this time have a DNP (Doctor of Nursing Practice), and two have PhDs as well. They are all PMHNP-BC (Psychiatric-Mental Health Nurse Practitioner-Board Certified). All are clinical faculty or adjunct faculty: Sheila Deyette (Specialty Track Director, also PhD); ElLois Bailey; Zoe Robbins (Clinical Director of Behavioral Health Faculty Practice); Sara Webb; Liz Greene; Randy Bullock (also a PhD); Elisa Warren; Cynthia Garbett; and Deborah Morgan (lead Dementia Care Specialist: Dementia Continuous Care Program, U of U Geriatrics Program and Hartford Foundation).

Students: Growth and Achievements. Of the 29 applicants to the PMHNP program for the Fall of 2023, 17 were accepted. Three applicants that had been accepted for the Fall of 2022 deferred to admission 2023. There will be, then, 20 new students in Fall 2023. In addition, there are 3 Nurse Practitioner students who will be taking the PMHNP Certificate Program. According to Dr. Deyette, there are 2 distance-students (one in rural southwestern Colorado, and one in southern Idaho). Last year there were 2 distance-students (one from Wyoming and one from Montana).

Last year’s College of Nursing graduates from the DNP-PMHNP had a 100% pass rate on the ANCC’s (American Nurses Credentialing Center) PMHNP Board Certification Exam.

In the Workplace. Current student feedback to faculty is often disappointment that at the practices where they are finding employment their work consists mostly of prescribing and managing psychotropic medications for patients. There is often little opportunity to conduct therapy. Other students do not object to a restricted scope of practice, stating that they are paid more for prescribing and medication management than for their skills as a therapist. They worry that they would have to take a pay cut if they wanted to do therapy as well as prescribing and managing medications.

The workplace is redefining Psychiatric-Mental Health Nurse Practitioners, narrowing the scope of their practice. If nurses are to continue being viewed as compassionate, supportive caregivers, new theories of practice and skill development will need to emphasize the humanistic and caring elements of clinical practice along with addressing the changing field of medication prescribing.

Caring Connections

Dr. Kathie Supiano continues as the Director of Caring Connections: A Hope and Comfort in Grief. This valuable program faced increased demands during the COVID-19 crisis. With considerable telehealth experience already in their skillset, Caring Connections group leaders were able to continue leading grief groups online. The demand was often specific to family members’ losses due to COVID-19, or to dealing with COVID-19 long-term health problems or extended recovery, what doctors were sometimes labeling long-COVID (“Long Haulers” COVID). These groups continue along with Loss Due to Suicide, Loss of a Spouse, Loss of a Child, Loss due to Dementia, and other life-altering losses.

A vital contributor to this important work, in January 2022, Dr. Lynn Reinke joined the faculty at the University of Utah as the Clair Dumke Ryberg Presidential Endowed Chair for End of Life/Palliative Care. Within the College, there is now a Caregiver Project, a Palliative Care Project, and other projects that Reinke and Supiano work on together.

Recognizing that the need for Grief Support services are more than Caring Connections alone could meet, Supiano is developing specialized programs for mental health providers to enhance their knowledge in treating the bereaved.

The Nurse Practice Act

The Nurse Practice Act changed again in 2021. The Consultation and Referral requirement was removed for all APRNs. As for APRNs with less than 1 year, or 2000 hours only, they are now required to maintain a 1000-hour mentoring relationship regarding schedule II Controlled Substance prescriptions and enroll in additional Continuing Education courses.

Finally, in 2023, the last remaining statutory barriers to practice were removed resulting in Utah nurses finally achieving full practice authority. The Utah House of Representatives passed the last vote needed to remove the Consultation and Referral Plan (CRP) agreement for Schedule II prescriptive authority, a requirement that had existed since those rules were first established in the beginning of Nurse Practitioner practice in Utah. ElLois Bailey, Zoe Robbins, and Julia Balk from the Psychiatric-Mental Health Nurse Practitioner group and Lee Moss from the Family Nurse Practitioner group worked closely with the Utah Medical Association group to pass this legislation.

Community

March 15, 2020, was the beginning of the shutdown in cities and states across the nation due to the COVID-19 threat. Academic endeavors made routine business, teaching, campus meetings, programs, activities, and research difficult. The adjustments often had to be made quickly. Student life as they knew it stopped and courses were often cancelled or moved to on-line formats.

The crush on nurses, physicians, and other health care workers was pronounced during the pandemic. Some parts of healthcare, such as elective surgery and procedures and most doctor

visits, closed down. But emergency rooms, primary care clinics, intensive care units, and other hospital medical units were overflowing and overwhelmed with patients. Limitations on visiting was hard on patients and family members and friends. Deaths were often unattended by loved ones, which added to the grief of family members. Due to the Surgeon General’s warning to avoid gatherings, especially in enclosed spaces, funerals were often online, with limited in-person attendance.

By 2023, most University personnel have adapted to the presence of the COVID-19 virus and its variants. New vaccines have made headway in protecting people from the more extreme, life-threatening symptoms caused by the virus. New medications, if taken early in the course of the disease, also seem to lessen its severity, although not for everyone. Many deaths still occur daily across the United States and around the globe. But there are fewer than the death toll was just a few short years ago. Utah began lifting its ban on many virus-related restrictions in March 2023, and many people are now taking the disease in stride.

Learning from the Past: Foundations and the Path Forward

How do you summarize 66 years of a nurse education program? Over this time, mental health care has progressed from restrictive, even harmful practices to more curative, compassionate models of care for people with mental illnesses. Today’s treatment interventions alleviate some symptoms and dramatically reduce others, promoting more long-lasting emotional and psychological well-being. The mystery of what causes severe mental illness is still illusive. Rather than approaching mental illness from a “nature vs. nurture” perspective, complementary approaches that offer both medication and psychotherapy are often more effective.

Genetics and other avenues of research, combined with sophisticated computer data, are starting to bridge the gap in our understanding of our brains. Many environmental factors that contribute to mental illness have been identified; yet it is still not clear how the mechanism of mental illness operates or what triggers it. Less severe mental illnesses often readily respond to psychotherapy and medications, and even those with severe mental illness may do so as well. However, these interventions are not universally available or sought out, and those with severe mental illnesses account for large portions of our homeless populations. Part of the problem is that medications for severe mental illness often have unacceptable side effects or else that patients sometimes don’t respond to them at all.

Suicide, addiction, and mental illness are societal ills that have not been solved. Much has been discovered or hypothesized but there is still much to be learned. For those who are afflicted, even with medications, living with a chronic mental illness is difficult, stressful, economically and emotionally taxing. In addition, family members of a mentally ill member strain to identify where they can be helpful and nurturing, without sacrificing everything they have, all their financial and emotional resources. More sustained and serious attention needs to be directed toward families and family safety nets as well as developing newer, more successful treatment approaches for individuals with mental illnesses. Without family support the mentally ill-homeless population will continue to grow.

Foundations to Stand On

Initially, graduate level programs in psychiatric nursing were an attempt to improve the treatment of traumatized war veterans of WWII, and hospitalized mentally ill patients who were hidden away or housed in asylums, or private institutions. Nurses and hospital attendants worked in close proximity with these patients on a daily basis. Nurses were clearly involved in the everyday care of people with mental illnesses, but if their care was to be more than merely custodial, their education needed enhancement. To that end, graduate psychiatric-mental health programs were encouraged and federally supported for many years.

As theories of illness, and theories of treatment evolved, nurses’ knowledge increased and their skill in working with mentally ill people was recognized. When the National Institute of Mental Health was created by Congress in 1949, nursing was one of the four core professions recognized in the field. The others were psychiatrists, psychologists, and social workers.

Graduate education for nurses to serve those with mental illnesses began in the late 1940s. Originally, courses were taught to prepare nurse educators. Those educators would promote the role of nurses to care for psychiatric patients. Gradually, graduate programs at academic institutions were developed to treat the mentally ill in outpatient settings.

The Community Mental Health Act of 1963 (CMHA), also known as the Community Mental Health Centers Construction and Mental Retardation Facilities and Construction Act, Public Law 88-164, changed the focus of mental health care from institutionalized care to public community-based care. The current theories were more applicable to outpatient treatment interventions. But there were significant unmet needs for the severely mentally ill. Unable to be cared for in their family homes (if they had any family ties), those with severe mental illness started living a wanderer’s life. Protective care was limited, funding was limited, and the freedom many experienced on the street was preferable to them than institutional care.

Early graduate psychiatric nursing education programs were supported by NIMH grants. Funding from NIMH covered student stipends, faculty support, and gave money to institutions that had these programs. The University of Utah graduate program in psychiatric nursing began with a grant from NIMH in 1957. A curriculum was adopted that was similar to other graduate psychiatric nursing programs. Psychopharmacology was still quite limited at that time. The program taught psychodynamic theories of mental illness and included medication management. It also focused on training in individual, family and group interventions. In the ‘60s, ‘70s, and ‘80s curriculum began incorporating and teaching other current theories and treatment interventions as they became available in professional literature.

The 1990s introduced the “Decade of the Brain” at NIH, out of which emerged a greater understanding of the biological underpinnings of many diseases, including but not limited to mental illness. By the late 1990s and 2000s with better understanding of neurology, theories of mental illness emphasized neurobiology. Pharmacology had developed a wide variety of new medications over the previous thirty years, adding significantly to the choice of treatment strategies for all mental illnesses, including severe mental illness.

According to data from SAMHSA (Substance Abuse and Mental Health Services Administration), most people being treated currently for a mental health diagnosis engaged in both therapy and medication management. Unfortunately for psychiatrists and psychiatric nurses, the workplace, focused as it is on income and reimbursement, has often defined their roles as only prescribers. Insurance companies pay better for prescribers than for psychotherapy interventions. Furthermore, prescribers can and often do see 3-4 people an hour, rather than the traditional therapy of an hour per patient.

The role for Advanced Practice Psychiatric Nurses is not set in stone. Both educators and practitioners have the power to define the future. Already, nurses in many fields have resisted being cast solely, or even primarily, in the role of “pill pusher” even though medication management has been and will remain an important part of nursing care. Far more than their skill in managing medication, however, nurses bring to the clinical arena their knowledge and understanding of human development, family dynamics, human behavior, anatomy, and physiology, not to mention their knowledge of pathophysiology, pharmacology, genetics, and background in other sciences, philosophies, and humanitarian service.

Voicing the Needs

New models of care need to be designed and evaluated. Here are a few issues to be addressed:

Can Psychiatric-Mental Health Nurse Practitioners prescribe and offer psychotherapy? How can that be incorporated in practice and reimbursed fairly?

Whether brief, or long term, it would be difficult to prescribe medications without gathering information similar to that gathered for psychotherapy. When two people are involved in treatment, there can be conflicting messages given to the client.

Can there be concurrent overlapping treatments by mental health professionals?

When there is more than one mental health professional treating an individual or family, there needs to be clear collaboration. What are the models for collaboration?

According to yearly Gallup Polls, nurses have topped the list of most trusted professionals ever since they were first included in 1999 on up to the last poll in 2022 (www.gallup.com, accessed 22 July 2023). In addition, nurses are in the top of respected professionals for their “expertise” and “societal impact.” (https://finance.yahoo.com) Given this level of trust and respect, how do Psychiatric Mental Health Nurses most effectively use compassion, trust, knowledge, as well as their skill in psychotherapy to help others?

Mental health is about people, their bodies and minds, their relationships, and about their lived experiences. And sometimes they go awry. Psychiatric-Mental Health Nurses can provide health care that integrates both physical and mental health strategies to assist those with mental Illness to improve, recover from, or adjust to their health problems. Psychiatric-Mental Health Nurse Practitioners (PMH-NP), or whatever their name will be in the future, will always be needed.

Most PMN-NP have focused on their clinical skills, which is very important, but there is so much more to the field and so much more that is needed. Perhaps most essential, critical, and immediately needed are thoughtful writers to articulate practice issues, treatment strategies, and successful collaborative communication patterns with other professionals.

Second, there is a serious need for Psychiatric Nursing Professionals who not only teach but conduct data-driven research that more clearly articulates nursing’s unique contribution to the advancement of mental health. As a science-based profession, nursing needs to study, analyze, evaluate, and disseminate its knowledge and practices. Nurse clinicians have the data from their practices that demonstrate their impact on their clients. Individual PMH-NPs or groups could greatly benefit from studying their own practices and sharing that knowledge with nurse educators and researchers. Yet, research is not only time-consuming and expensive, but is often not acknowledged or valued by clinicians. Although there is both a need and nurses who are interested in pursuing education in the field of mental health, there is little outside funding for these advanced programs. Federal funding for graduate mental health programs, including research, has diminished even as the need for it has grown. Funding for education is always a dilemma.

Third, nursing theories of treatment need to be articulated for the mentally ill and their families. Understanding and clearly articulating the reasoning or principles of PMH-NP practice provides others with knowledge about the profession and its goals and, most important, why a particular model of care will improve the mental health of a patient. Adapting theories from other disciplines is appropriate, but there needs to be a clear linkage between why those theories are appropriate for the nursing profession. For example, Sullivan’s Theory of Interpersonal Psychiatry was clearly adapted to nursing by Hildegard Peplau. Nursing theory is the underpinning of practice. Clearly articulated theory verified through responsible study and research, advances the health and wellbeing of our families and friends and society in general. Nurses, both in practice and as educators, need to find their own words to describe what they are doing as clinicians, as teachers, as researchers.

But there is more that the profession needs. We need to safeguard the profession. As noted in this document, the Nurse Practice Act was nurtured over many decades by nurses who worked with other disciplines advocating for changes that would allow nurses to practice to the full extent of their knowledge and skill. Still there need to be watchdogs to keep track of any changes that might be proposed to alter the Nurse Practice Act. So, fourth, the profession needs more nurses to contribute to the larger sphere of mental health. Nurses who are willing to donate their time and attention to engage in policy, both locally, and nationally, to advance the profession of nursing. To provide evidence for this endeavor, nurse historians are needed to track the ups and downs of a profession’s growth. Without a history there is no learning from the past, no foundation to stand on, and no clear path forward.

And finally, we need leaders. Willing leaders to move the profession forward through organizations that will bring about legislative action that benefits those with mental illnesses and their families. Outstanding, capable leaders in practices. Dedicated leaders in teaching, research, and administration. We need leaders with vision, energy, and ability. While there is no perfect leader, there are rallying points that can help us help each other and help and heal others. And that is our overarching goal: Take care of yourself as you care for others.