Whitney Palmer

Healthcare. Politics. Family.

Becoming a safe place: Program trains nurse practitioners to help neighbors

Published in the Winter 2007 Carolina Nursing Alumni Magazine

By Whitney L.J. Howell

When a mother brought her two adolescent boys into the Child and Family Center for Health in Durham, N.C., for treatment, Cliff Thompson, RN, knew he didn’t just have two patients. He had three. While trying to hold her family together, the mother was trapped in a vicious cycle of domestic violence and drug abuse.

The woman’s husband and boys’ father routinely used drugs and physically abused his family. Over the next year, Thompson helped her realize that she had the strength to assume official control of her family and become the head of the household.

“I helped her reframe her life and see what relationships were healthy and which ones weren’t,” Thompson said. “She was able to stand up to her husband and has filed separation papers.  She and her sons have moved on to a much healthier place.”

Thompson was able to make a difference for this family and others by being a student in the Nurses Enhancing Mental Health Options for the Underserved in North Carolina (NEMHOUNC) program at the UNC-Chapel Hill School of Nursing (SON).

This program recruits and trains students who are from either minority or disadvantaged backgrounds to be psychiatric and mental health clinical nurse specialist/nurse practitioners in their home communities. Thompson will graduate in August 2008 with an MSN degree and qualifications as both a clinical nurse specialist (CNS) and a psychiatric-mental health nurse practitioner (PMH-NP) degree.

After completing the program, Thompson, who is black, intends to become a psychiatric therapist and, eventually, have his own practice. He hopes that he and other nurses like him will add to the quality and availability of mental health services in North Carolina.

“With so many ongoing changes in the state mental health system, NEMHO graduates will prevent many people from slipping through the cracks,” he said.

“It’s an amazing service we provide— once you’ve developed a trust, people will tell you things they’ve told no one else. You become a safe place for them.”

Current State of Mental Health

Each year, North Carolina hospitalizes 1 million people for mental health reasons. In addition, according to N.C. Department of Health and Human Services (DHHS) estimates, 322,000 nonhospitalized citizens have a diagnosable mental disorder that limits at least one major life activity, and an additional 99,000 have a severe and persistent mental illness that completely prevents them from managing daily life. On top of these numbers, more than 852,000 citizens need help for substance abuse, but in 2000, only 1 percent actually received that aid.

To make mental health services more accessible, widespread changes over the past six years have radically changed how state services are controlled. A 2001 law switched the mental health system from one directed by the public sector to one managed by private companies. Now, local governments monitor the companies to ensure patients receive the help they need. But, 15 percent of patients—those who are poor but don’t qualify for Medicaid or those with hard-to-treat problems—are still being left behind.

According to DHHS data, along with privately-managed services, there are 15 state facilities to assist adults who request help, but only five facilities are psychiatric hospitals. Of those, two hospitals, Dorothea Dix in underserved Wake County and John Umstead in Butner County, will close in late 2007 or early 2008. A new facility, Central Regional Psychiatric Hospital in Butner, will replace these institutions, leaving Wake County without a state-run mental health hospital.

Once Wake County has no public mental health inpatient institutions, nurse practitioners will become a critical part of psychiatric services there.

“There is a definite community role for psychiatric nurse practitioners,” said Margaret Raynor, director of medical education at Dix Hospital. “They can see people as individuals, treat them at home and have a better chance of keeping them out of a facility and on their medication.”

The state is also experiencing a decline in the number of licensed psychiatrists who work in communities. With hospitals also closing, many people who need mental health services aren’t getting them.

But that’s about to change, said Michael Moseley, director of the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse. The N.C. mental health system is restructuring to bring more mental health services into rural communities.

“We are shifting the system in terms of how we support people with mental health needs,” Moseley said. “We want to take services to the people who, historically, have not been served until they were in a crisis.”

Where the SON Can Help

This is where NEMHO fits in. It’s a bridge between these underserved communities and the state department of mental health, according to SON professor Linda Beeber, PhD, RN, CS, FAAN, who designed the program. Over time, she hopes NEMHO will be integrated into the state mental health system.

“I envision that psychiatric-mental health nurse practitioners will really take the lead in helping build up capacity to care for people with mental health needs,” she said. “The state will still need to care for those with the most severe mental illnesses, and NEMHO graduates can relieve the state’s burden by providing consistent, high-quality care to those who need help but who can also function within the community.”

The three-year project supports both Healthy People 2010, a national health promotion and disease prevention initiative, and the new state goal of bringing mental health services to minority and disadvantaged citizens who need them.

The Health Research and Services Administration (HRSA) in the U.S. Department of Health and Human Services funded the program with a $669,647 grant from 2004–2007. A continuation of the grant for $575,110, received in July 2007, will bolster efforts to recruit more qualified nurses. Faculty member Victoria Soltis-Jarrett, PhD, APRN-BC, clinical associate professor and coordinator of the MSN psychiatricmental health program, is the principal investigator on this grant. The state department of mental health is also a stakeholder in the program, supplying it with $160,000 of funding.

Currently, NEMHO has 17 students from 15 counties surrounding Chapel Hill and some from the western- and eastern-most portions of North Carolina. Approximately 50 percent of enrollees are minority or disadvantaged students. The school is making a special effort to attract students from diverse backgrounds because it wants to extend psychiatricmental health expertise to qualified nurses who would not otherwise enroll in a UNC program for financial or logistical reasons. Faculty actively recruit students with the help of an advisory board, a targeted recruitment plan and student recruiters.

From the perspective of state mental health officials, these recruitment efforts are the first steps to enhancing and changing the face of healthcare.

“Part of what we’re looking at in the mental health system nationwide is a workforce that is insufficient in numbers,” said Michael Lancaster, MD, chief of clinical policy for the N.C. Division of Mental Health, Developmental Disabilities and Substance Abuse.

“Graduates of the NEMHO program are attractive and exciting because they introduce a new type of clinical provider that hasn’t been part of the workforce before.”

Once several classes of NEMHO students graduate, Lancaster said, the state will feel the benefit. Individuals suffering with mental illness who are treated as outpatients will have increased access to mental health assistance and the support services they need. NEMHO graduates will be in the unique position to provide more extensive and consistent care to this particular patient population than hospitals can, he said.

As students graduate and begin their own practices, they create compassionate care environments as part of a healthcare team. They properly implement advanced nursing interventions, expertly dispense psychotherapy and prescribe and manage medications. According to the SON’s Beeber, NEMHO students will treat more than mental health conditions.

“The care these CNS/NPs provide is not just related to mental health— it’s about health in general,” she said. “It’s treatment and help for mental illness and for life. And, it’s not just about the individual patient. It’s about the community in which they live.”

That community could be a group living facility, the patient’s co-workers, the patient’s family and children or any group he or she cares about. NEMHO graduates are trained to help anyone associated with the patient learn how to live with the illness and help the patient be as healthy as possible.

In order to do that, NEMHO students go through extensive training, and program coordinators have revamped the traditional curriculum to allow students to stay closer to their clients. Faculty are now using a Contextually Enhanced Learning (CEL) curriculum that combines distance education, intensive residential classes, partnerships with Area Health Education Centers (AHECs) and a mental health advisory board to train students.

Pat Hayes, director of nursing education at the Mountain Area Health Education Center, said using CEL will benefit areas that already have critical shortages of mental health providers.

“Throughout parts of North Carolina, we are in a crisis without enough community services,” Hayes said. “NEMHO students will be a great help because so many of them are native to underserved communities and will stay here to provide care.”

The grant provides most equipment the students need to successfully complete the program, including laptop computers, Web cameras, software and telephone/ cable connections. Consequently, students only spend three long days on campus each semester. The rest of the time, they attend lectures and participate in discussion groups via the Internet.

Learning in the Community

To graduate, students must complete between 500 hours and 900 hours of clinical training at program-approved clinical sites. NEMHO administrators chose sites where clients of all ethnicities and mental health needs seek assessment and treatment. Preceptors monitor the students’ progress, offer guidance and prepare students to care for mentally-ill adults, children and adolescents. In most cases, students work at sites within one to two hours distance from their homes.

Students conduct psychiatric intakes, often assessing walk-in clients, determining what the problem might be and deciding on the best treatment plan. Working with these clients and their families helps students hone their psychotherapy and group therapy skills, as well as become proficient in drug prescription and management. If clients need daily help, students decide on a community support placement that will be the most beneficial, and, on occasion, students make referrals for primary care.

This clinical work isn’t just real-world experience—it has theory and research applications, as well, Beeber said.

“Students use what they’ve learned hands-on to design what they envision as their own dream mental health facility,” she said. “They have to determine what’s good and bad in the current system and create something they think would provide the best care.”

When presenting their dream facility, students outline who the facility would serve, what evidence- based services would be appropriate and what strategies would be in place to target and reach underserved populations. The exercise pushes students to see where they can make improvements in the mental health system, Beeber said. NEMHO students and graduates understand the importance of what they’re studying and the commitment they’re making to underserved populations in need, Soltis-Jarrett said.

Even though many of them are already working with psychiatric-mental health patients, they realize they could do much more with extensive training.

“Students recognize the huge problem out there with mental health. Many of them are already contributing much-needed services, but they want more education,” Soltis-Jarrett said. “Working with the mental health patient population without training is like hitting a golf ball without taking lessons. You can do it, but with lessons, your shot is much better.”


May 27, 2010 - Posted by | Healthcare | , , , ,

1 Comment »

  1. Hi! Very interesting read. Will follow this.

    Comment by Diandio | June 21, 2010 | Reply

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