Journal of the American Psychiatric Nurses Association recent issues

Transcranial Magnetic Stimulation (TMS): An Entirely Novel Form of Treatment in Psychiatry and a Groundbreaking Opportunity for Psychiatric Mental Health Nursing

Rosedale, M. — Wed, 11 Nov 2009 15:46:51 PST

Focus Issue Reviewer Acknowledgment

Wed, 11 Nov 2009 15:46:51 PST

A Review of Studies Comparing Methods for Determining Transcranial Magnetic Stimulation Motor Threshold: Observation of Movement or Electromyography Assisted

Anderson, B. S., George, M. S. — Wed, 11 Nov 2009 15:46:51 PST

BACKGROUND: Early in the development of transcranial magnetic stimulation (TMS) as a research tool, scientists developed the concept of motor threshold (MT) as a method of quantifying dose and establishing safety. Neurophysiologists determined the MT with the aid of peripheral electromyography (EMG). More recently, clinicians started substituting the EMG with observed movements (OM) of the hand or digits. It is unclear whether the two approaches (EMG and OM) reach similar conclusions about an individual’s cortical excitability and when best to use each approach. OBJECTIVE: To review TMS studies directly comparing the EMG and OM MT methods. DESIGN: A systematic search of the literature on Medline from January 1995 through April 2008. RESULTS: Four articles directly compared the two approaches, reaching different and opposing findings. CONCLUSION S: The evidence supporting the substitution of EMG with OM is sparse and conflicting. Clinicians stimulating at or near safety guidelines should use the EMG method.

Effective Utilization and Future Directions for Repetitive Transcranial Magnetic Stimulation: A Guide for Psychiatric Nurses

Fitzsimons, L., Disner, S. G., Bress, J. N. — Wed, 11 Nov 2009 15:46:51 PST

Repetitive transcranial magnetic stimulation (rTMS) and magnetic seizure therapy (MST) represent new and promising avenues for treating mild and severe treatment-resistant depression, respectively. A further understanding of these modalities and the contribution of psychiatric nurses in the emerging field of brain stimulation would be of great use to the nursing community. This article serves as a primer for those who are interested in participating in or referring patients for research or treatment with rTMS or MST. Of particular emphasis is the role of certified psychiatric nurses as clinical rater, patient liaison, and evidence-based practitioner:

A Psychiatric Nurse's Perspective: Helping Patients Undergo Repetitive Transcranial Magnetic Stimulation (rTMS) for Depression

Bernard, S., Westman, G., Dutton, P. R., Lanocha, K. — Wed, 11 Nov 2009 15:46:51 PST

With the October 2008 Food and Drug Administration approval of repetitive transcranial magnetic stimulation (rTMS) for depression treatment, the establishment and administration of rTMS clinical treatment programs are critically important and emerging areas for psychiatric nursing leadership. There is growing recognition that many patients are unable to tolerate antidepressant medications and require alternative antidepressant treatment approaches. The enormous growth in the field of brain stimulation creates exciting new therapeutic options for patients with treatment-resistant depression. As with any clinical breakthrough, new treatments offer exciting possibilities but also require growth in psychiatric nursing knowledge, different practice competencies, and new ways of organizing care. This article discusses current practice guidelines, psychiatric nursing qualifications, and essential details about developing an rTMS clinical service. This is the first article to describe the role of a psychiatric nurse establishing a clinical rTMS service, administering rTMS, and helping patients undergo the treatment. The authors share the progress made and the lessons learned.

The Structure of the Lived Experience for Persons Having Undergone rTMS for Depression Treatment

Rosedale, M., Lisanby, S. H., Malaspina, D. — Wed, 11 Nov 2009 15:46:51 PST

OBJECTIVE: This phenomenological research study reports preliminary findings about experiences of persons undergoing repeated transcranial magnetic stimulation (rTMS) for depression treatment. METHODS: Giorgi’s phenomenology was the method used to describe the structure of the lived experience for persons having undergone rTMS treatment for depression. Participants were recruited from the OPT-TMS pivotal depression study that resulted in the October 2008 FDA approval of rTMS. Thus far, nine persons comprise the purposive sample. Each participant was asked to describe the experience of undergoing rTMS for depression treatment and encouraged to provide as much details as possible. RESULTS: Four preliminary themes emerged to describe participants’ experiences of rTMS for depression treatment: (a) a narrative of frustration and helplessness with medication treatment resistance, (b) the sensory experience of rTMS, (c) mindfulness— an enhanced awareness of the content of consciousness, and (d) the importance of connection with clinicians. CONCLUSIONS: Preliminary results of this phenomenological study make the struggle of persons with treatment-resistant depression more visible and should assist clinicians to understand how rTMS is experienced by depressed persons undergoing treatment. Moreover, results shed new light on the changes participants observe and describe with rTMS and the high value they place on a therapeutic relationship with clinicians administering treatment.

Boundaries: The Nurse Scientist and Care Provider

Stein, K. F. — Mon, 14 Sep 2009 10:20:09 PDT

Evaluating Differential Item Functioning of the CES-D Scale According to Caregiver Status and Cultural Context in Korean Women

Choi, H., Fogg, L., Lee, E. E., Choi Wu, M. — Mon, 14 Sep 2009 10:20:09 PDT

BACKGROUND: Proper evaluation of the generalizability of an instrument is critical for its use across different social contexts such as caregiver status. OBJECTIVE: To examine the differential item functioning of the Center for Epidemiologic Studies Depression (CES-D) Scale, patterns of response to each item of the CES-D Scale attributable to caregiver status was assessed. STUDY DESIGN: Using a cross-study comparison method, a sample of 58 matched pairs of Korean American caregivers and noncaregivers was used for matched moderated regression analysis on the CES-D Scale. RESULTS: The authors identified three items that vary according to caregiver status in the present study: Item 2 (My appetite was poor), Item 4 (I felt that I was as good as other people), and Item 14 (I felt lonely). CONCLUSIONS: Beyond assessing the level of depression through total CES-D scores, it is important to examine variations in the items of the CES-D Scale across different social contexts. J Am Psychiatr Nurses Assoc, 2009; 15(4), 240-248. DOI: 10.1177/1078390309343713

Meeting the "Now" Need: PMH-APRN-- Interpreter Teams Provide In-Home Mental Health Intervention for Depressed Latina Mothers With Limited English Proficiency

Beeber, L. S., Lewis, V. S., Cooper, C., Maxwell, L., Sandelowski, M. — Mon, 14 Sep 2009 10:20:09 PDT

Latina mothers of infants and toddlers are at high risk for developing serious depressive symptoms if they are newly immigrated and have limited English proficiency (LEP). Depressive symptoms compromise these mothers and result in severe consequences for their U.S.-born children. A randomized clinical trial of a short-term, in-home psychotherapy intervention for symptomatic mothers in an area of the United States where bilingual mental health providers were scarce used teams of English-speaking advanced practice psychiatric mental health nurses and bilingual community interpreters who were trained in a conduit, consecutive model of interpretation. The article describes the development of a theoretically congruent interpreter model, the training program that supported it, the challenges that surfaced and lessons learned during successful implementation in the field. Future refinements in progress and uses of the model are discussed.

Executive-Level Reviews of Seclusion and Restraint Promote Interdisciplinary Collaboration and Innovation

Allen, D. E., de Nesnera, A., Souther, J. W. — Mon, 14 Sep 2009 10:20:09 PDT

Elimination of seclusion and restraint requires support at all levels of an organization, especially from leaders who visibly champion and communicate their vision. Nurses, physicians, educators, and administrators at New Hampshire Hospital, an acute psychiatric inpatient facility, have established a standard meeting time and place for an executive-level review of every episode of seclusion and restraint. The standing meeting demonstrates the organization’s commitment to caring for both patients and staff. The daily meetings foster a spirit of interdisciplinary collaboration, where direct care staff have the opportunity to tell their stories and share their ideas and concerns in an environment that is caring, supportive, and devoid of criticism or blame. Narrative descriptions of emergency interventions, including what was learned from debriefings with patients and staff involved, provide data about factors that may contribute to the use of seclusion or restraint. This forum provides visible administrative and clinical support that promotes creative thinking, collaborative problem solving, and the exploration of new ideas recommended by those directly involved in providing patient care. It has fostered exploration and development of strategies that have minimized episodes of aggressive behavior as well as seclusion and restraint.

An Interview with Dr. Carole Shea: On Becoming an Academic Nursing Leader

Kaas, M. J. — Mon, 14 Sep 2009 10:20:09 PDT

Evidence-Based Psychiatric and Mental Health Nursing: Responsibilities and Their Distribution

Farchaus Stein, K. — Mon, 29 Jun 2009 12:33:00 PDT

Report From a National Tobacco Dependence Survey of Psychiatric Nurses

Sharp, D. L., Blaakman, S. W., Cole, R. E., Evinger, J. S. — Mon, 29 Jun 2009 12:33:00 PDT

BACKGROUND: Persons with mental illness smoke proportionately more cigarettes and die earlier than the general population. Yet compared with other clinicians, psychiatric professionals have intervened slowly with smoking patients. To assess psychiatric nurses' perspectives concerning tobacco dependence interventions, the American Psychiatric Nurses Association (APNA) Tobacco Dependence Task Force surveyed email-accessible APNA members (N = 1,365). OBJECTIVES: This paper reports survey results and implications for psychiatric nursing. STUDY DESIGN: Cross-sectional analysis of a 29-item online survey conducted in early 2008. RESULTS: Most nurses asked if patients smoked but fewer advised against smoking, referred to cessation resources, or delivered intensive interventions. Nurses referred to resources if they felt motivated, knowledgeable, and/or confident in their skills and rated highly their patients' ability and/or motivation to quit smoking. Workplace characteristics were related to nurses' behaviors. Nursing curricula lack tobacco dependence content. CONCLUSIONS: Findings will guide efforts to support nurses in reducing/eliminating smoking by their patients through practice, education, research, and policy initiatives.

Estimating Person--Environment Transactions on Intention to Change Drug-Using Behaviors

Matto, H. C., Spera, C. — Mon, 29 Jun 2009 12:33:00 PDT

The community attachment model of addiction is an ecologically based social process model that suggests social context referents (peers, family, neighbors, etc.) will influence attachment to addiction or recovery communities, via cognitive, affective, and behavioral commitments. This study examined the influence of social context referents on intention to change drug using behavior, and examined moderating effects of three contextual indicators (labor market attachment, educational attainment, and family poverty status) on these relationships. The study sample consisted of 302 adults in inpatient and outpatient substance abuse treatment facilities, who completed a set of instruments that included the Ecological Assessment of Substance Abuse Experiences (EASE), a new instrument designed to measure the influence of social context referents on addiction and recovery attachment processes. Results showed that all three contextual indicators moderated relationships among social context referenced attitudes, drug use concern, and intention to change drug using behaviors. Findings suggest that practitioners should attend to both microlevel orientations to social context and macrolevel contextual dimensions (e.g., labor force attachment), as both may influence behavioral change opportunities.

Mental Health Patients' Experiences of Being Misunderstood

Gaillard, L. M., Shattell, M. M., Thomas, S. P. — Mon, 29 Jun 2009 12:33:00 PDT

BACKGROUND: Mental health patients describe "being understood" as an experience that evokes feelings of importance, worthiness, and empowerment. However, the experience of "being misunderstood" is more prevalent in patients' relationships with health care providers. Negative consequences such as vulnerability, dehumanization, and frustration reveal that being misunderstood has the potential to damage or destroy therapeutic relationships. OBJECTIVE: The purpose of this secondary analysis was to examine mental health patients' experiences of being misunderstood. STUDY DESIGN: Data consisted of transcripts from 20 interviews with community-dwelling adults with mental illness, which were analyzed using an existential phenomenological approach. RESULTS: Four figural themes expressed the experiences of being misunderstood: protection from vulnerability, an object to be fixed, treated like a child, and relentless frustration. CONCLUSIONS: Nurses and other caregivers can use the findings of this study to promote understanding, strengthen therapeutic relationships, and improve the quality of mental health care.

The Importance of Qualitative Research to EBP

Rice, M. J. — Mon, 29 Jun 2009 12:33:00 PDT

Evidence-Based Practice: Critical Appraisal of Qualitative Evidence

Williamson, K. M. — Mon, 29 Jun 2009 12:33:00 PDT

One of the key steps of evidence-based practice is to critically appraise evidence to best answer a clinical question. Mental health clinicians need to understand the importance of qualitative evidence to their practice, including levels of qualitative evidence, qualitative inquiry methods, and criteria used to appraise qualitative evidence to determine how implementing the best qualitative evidence into their practice will influence mental health outcomes. The goal of qualitative research is to develop a complete understanding of reality as it is perceived by the individual and to uncover the truths that exist. These important aspects of mental health require clinicians to engage this evidence.

Information for Authors

Tue, 12 May 2009 18:01:36 PDT

National Survey of Psychiatric Mental Health Advanced Practice Nursing: Development, Process, and Finding

Drew, B. L., Delaney, K. R. — Tue, 12 May 2009 18:01:36 PDT

A survey was sent to all Psychiatric Mental Health (PMH) Advanced Practice Registered Nurses (APRNs) who had a registered e-mail address with the American Nurses Credentialing Center, resulting in 1,899 usable surveys. The practice of two groups of APRNs was examined and contrasted: those certified to treat children and adolescents and PMH-APRNs certified only to treat adults. Our findings raise concerns about the numbers of PMH-APRNs treating children. Considering the national demand for mental health professionals prepared to treat children, the specialty must move to increase the number of qualified APRN child providers.

A Comparison of the Practices of Psychiatric Clinical Nurse Specialists and Nurse Practitioners Who Are Certified to Provide Mental Health Care for Children and Adolescents

Weiss, S. J., Talley, S. — Tue, 12 May 2009 18:01:36 PDT

BACKGROUND: A task force of the American Psychiatric Nurses Association and the International Society of Psychiatric Mental Health Nurses initiated a survey to identify how advanced practice psychiatric nurses were addressing the mental health needs of children and adolescents. OBJECTIVES: Practice patterns of Child and Adolescent Psychiatric—Mental Health Nurses (CACNSs) and Family Psychiatric Nurse Practitioners (FPNPs) were compared. DESIGN: An electronic survey was completed by 234 CACNSs and 170 FPNPs from a national database. Group data were compared using descriptive and inferential statistics. RESULTS: Both groups spent the greatest percentage of their time in medication management, with depression being the most frequent problem they treated. However, CACNSs treated more school-aged children and provided more psychotherapy. FPNPs frequently merged prescribing and therapy when seeing patients. CONCLUSIONS: Findings indicate more commonalities than differences in the practices of the two certification groups but suggest the need for standards that will inform educational programs and certification examinations.

The Clinical Nurse Leader: Helping Psychiatric Mental Health Nurses Transform Their Practice

Seed, M. S., Torkelson, D. J., Karshmer, J. F. — Tue, 12 May 2009 18:01:36 PDT

The national movement to transform the health care delivery systems must include a focus on mental health treatment. To address similar deficits across other practice domains, the Clinical Nurse Leader (CNL) role has been created. The CNL is a master's degree that prepares a nurse to use a systems perspective to improve outcomes for a cohort of patient, deliver care based on best practices, and coordinate care in a multidisciplinary team. Applying the CNL role to mental health care could help psychiatric mental health nursing be at the forefront in the transformation of mental health care delivery.

Applying Benner's Model to Psychiatric Mental Health Nurse Practitioner Self-Ratings of Role Competence

Alber, L., Augustus, L., Hahn, S., Penkert, J., Sauer, R., DeSocio, J. — Tue, 12 May 2009 18:01:36 PDT

BACKGROUND: Cross-sectional survey research elicited self-perceptions of role competence from practicing psychiatric mental health nurse practitioners (PMHNPs) and new PMHNP graduates. OBJECTIVES: Examine relationships between PMHNP perceptions of competence, prior basic-level nursing experience, and years of PMHNP practice. STUDY DESIGN: Self-ratings of competence were elicited by a questionnaire designed from Benner's model. The relationship between prior nursing experience and perceptions of competence was examined by chi-square analysis. Changes in PMHNP competence rankings over years of practice were examined with Kruskal—Wallis and Mann—Whitney procedures. RESULTS: Self-perceptions of competence increased in seven role dimensions as PMHNPs progressed through years of practice (p < .000). Gains in perceptions of competence occurred between career entry and 3 to 5 years of practice in all but one role dimension. Prior nursing experience did not significantly increase perceptions of competence among PMHNP graduates. CONCLUSIONS: Self-perceptions of competence progressively and significantly increased over years of PMHNP practice among participants in this study.

Effect Size in Psychiatric Evidence-Based Practice Care

Rice, M. J. — Tue, 12 May 2009 18:01:36 PDT

Developing evidence-based practice skills requires a familiarity with the language and terminology of clinical research. Few articles discuss concepts, such as effect size, that must be understood to determine if the findings of studies are clinically meaningful. Clinically meaningful results of studies are determined by the effect size of an intervention. The effect size of an intervention, such as cognitive—behavioral therapy, can be calculated from the findings of different studies using different designs and populations. However, the determination and use of an effect size is important to clinicians using research findings to guide practice.