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Constraints to Advanced

Psychiatric-Mental Health
Nursing Practice
Patricia B. Howard and Doris Greiner
Constraints and barriers to advanced practice psychiatric nursing were
reported by respondents of the Primary Mental Health and Advanced
Practice Psychiatric Nursing survey of certified psychiatric clinical nurse
specialists. Primary data (N = 507) were the qualitative responses to a
survey item about constraints and secondary data were the literature and
theoretical memos. Methodology was based on principles of qualitative
data analysis and procedures for manifest and latent content analysis.
Findings resulted in eight themes that explained both constraints and
barriers to advanced practice: (1) reimbursement, (2) prescriptive authority, (3) admitting privileges, (4) bureaucracy, (5) practice environment, (6)
colleagues, (7) image, and (8) personal. Themes were interpreted within
the context of regulatory, market-based, and inter/intraprofessional constraints and barriers that led to suggestions for organizational and individual strategies for action. The survey was funded by the Society for
Education and Research in Psychiatric-Mental Health Nursing with technical support from the Center for Mental Health Services.
Copyright 1997by W.B. Saunders Company

EALTH CARE AND mental health care have


changed dramatically in recent years. Advanced Practice Psychiatric Nurses (APPN) have a
history of managing change and dealing with
constraints to their practice with enthusiasm. They
have consistently challenged the limits of the
practice situations they are in, working to improve
services for patients and developing theories and
models that have guided this practice (Olsen,
1996). Because much of the work with patients/
clients and families is private or hidden work, a
continuing lack of awareness of the work of APPNs
plagues the profession (Safriet, 1994).
A national survey was conducted to document
existing APPN practices (Society for Education

From the College of Nursing, University of Kentucky,


Chandler Medical Center, Lexington, KY and the School
of Nursing, University of Virginia, Charlottesville, VA.
Address reprint requests to Patricia B. Howard, PhD,
RN, CNAA, University of Kentucky, College of Nursing,
Chandler Medical Center, Lexington, KY40536-0232.
Copyright 1997 by W.B. Saunders Company
0883-9417/97/1104-000553.00/0

198

and Research in Psychiatric Mental Health Nursing


[SERPN], 1997), in part because of a lack of data
regarding the actual practices of APPNs in the
current climate of change. The purpose of this
report is to describe constraints and barriers in the
advanced practice world of APPNs using data from
this national survey. Participants in the survey were
asked to describe constraints to their practice.
Unlike barriers that are external obstacles that bar
progress or access, a constraint is a limitation or
restriction that can be experienced either internally
or externally (Webster's Dictionary, 1993). It is the
intent of this interpretive work to make explicit
both the constraints and the external barriers to
practice as they are being experienced by the
participants in the survey. These qualitatively different phenomena call for different responses on the
part of the profession.
RELATED LITERATURE

A brief discussion of three broad categories of


barriers and constraints found in the literature

Archives of Psyehiatric Nursing, Vol. XI, No. 4 (August), 1997: pp 198-209

CONSTRAINTS TO ADVANCED NURSING PRACTICE

provides the context for the interpretation of the


data from the survey. These categories are regulatory barriers, market-based constraints and barriers,
and inter/intraprofessional constraints.

Regulatory Barriers
Safriet (1992) identified the three most significant regulatory barriers to advanced practice in
nursing as unnecessary restrictions on scope of
practice, limits on prescriptive authority, and reimbursement. Based on analysis from a legal perspective, she argues for legislative reform that would
allow advanced practice nurses (APNs) to provide
the health care they are capable of delivering.
Although she restricted her discussion to nurse
practitioners (NPs) and certified nurse-midwives
(CNMs), the arguments she advanced apply to
APPN practice barriers as well. The direct clinical
practices of all advanced practice nurses touch the
perceived overlapping boundaries of medical and
nursing practice. Nurses are consequently subjected to regulatory control that is inconsistent from
state to state. Fortunately, there are some signs that
this may be beginning to change. In the annual
update for nurse practitioners on legislative issues
affecting advanced nursing practice, Pearson (1995)
documented the fact that state legislative practice
restrictions are beginning to break down. In 1994,
no state became more restrictive, and 12 states
added independent prescriptive authority or modified existing statutes to make them less restrictive.

Market-Based Barriers
Malpractice insurance and admitting privileges
are examples of barriers and constraints in this
category. They are not directly created by statute,
although legislation does have beating on them. An
investigation of state practice environments and the
supply of NPs, nurse-midwives, and physicians
prompted one group of investigators (Sekscenski,
Sansom, Bazell, Salmon, & Mullan, 1994) to
conclude that factors other than those they had
identified affected the practice environment in
important ways. Legal status, reimbursement, and
authority to prescribe influenced supply, but they
are far from the whole story. Rather, these investigators concluded that acceptance as professionals by
physicians, inclusion for reimbursement in health
insurance policies, and acceptance by the public
were important determinants of supply at commu-

199

nity, regional, and state levels. They were unable to


determine whether a greater supply led to a removal of regulatory barriers or vice versa. Similar
market-based constraints as well as interprofessional and intraprofessional constraints were described by a group of nurses in Michigan (Hagerty,
Bissonnette, Bostrom, Lowell, & Seiloff, 1995).

Interprofessional and Intraprofessional


Constraints
Acceptance as professionals by physicians as
described by Sekscenski et al. (1994) is one aspect
of this complex set of considerations. In a 1994
survey of the practice of clinical nurse specialists,
both facilitators and barriers were identified (McFadden & Miller, 1994). These nurses were primarily hospital based (85.7% of the 288), and they
reported that the support of nursing administration
was crucial to their success. Although few identified physician support as essential, they did describe physicians as valuing them more highly than
their nurse colleagues.
A survey conducted by the Michigan Nurses'
Association (MNA) Psychiatric-Mental Health
Nursing Practice section resulted in a report that
was based on findings from field data obtained
from a sample of psychiatric nurses (Hagerty et al.,
1995). Respondents to the MNA survey identified
lack of cohesion or a shared vision among members
of the multidisciplinary mental health care team as
a major constraint. Findings also indicated that
respondents perceived little support for their work
among nursing administrators and colleagues in
other nursing specialties. These inter- and intraprofessional issues were viewed as contributing factors to the general public's lack of clarity about the
role of psychiatric nurses (Hagerty et al., 1995).
Other constraints reported by Hagerty et al. could
be construed as regulatory or market-based barriers. Those constraints included general lack of
financial support for the delivery of mental health
services and specific lack of funds available to
psychiatric nurses from third party reimbursement.
Within this context of barriers and constraints
APPNs continue to provide effective, safe care to
clients and families. The APPNs who participated
in a survey conducted by a Research Task Force of
SERPN described characteristics of their current
practices and wrote about constraints to those
practices.

200

HOWARD AND GREINER

METHODOLOGY
This study was part of the Primary Mental
Health and Advanced Practice Psychiatric Nursing
Survey funded by SERPN from 1994 to 1997. The
research project featured triangulation of methods
(SERPN, 1997). Methodology for this study about
constraints to practice was based on principles of
qualitative data analysis (Lincoln & Guba, 1989;
Patton, 1990), a study design that involved procedures recommended for manifest and latent content
analysis (Catanzm'o, 1988) and the constant comparative method (Glaser & Strauss 1967). To
ensure compatibility and consistency with the principles of naturalistic inquiry, criteria for trustworthiness much like those described by Lincoln and
Guba (1989) were established.
For example, the importance of flexibility was
taken into account, yet rules were delineated for
coding, classifying, and quantifying the textual
data that included some data management with the
computer software program Martin (University of
Wisconsin, Madison WI). Simultaneously, investigator roles and boundaries for steps of the research
process that emphasized adequate time for examining and synthesizing the data were agreed on. To
enhance synthesis, protocols were established for a
minimum of three levels of analysis for development of meaningful concepts that accurately depicted the reported constraints. Procedures for both
independent and joint data analysis were developed
because the investigators' differing practice and
research expertise in psychiatric nursing fit the
criteria for investigator triangulation (Kimchi, Polivka, & Stevenson, 1991; Patton, 1991). Peer
debriefing strategies included research team involvement and feedback. Finally, theoretical and methodological memos for audit purposes were developed.
In essence, the plan for trustworthiness was used as
a guide for promoting credibility of the larger study
(SERPN, 1997) as well as this one.

The unit of analysis for this study was responses


to the single survey item: Identify constraints to
your practice. It is important to remember that this
question was not the primary focus of the survey.
Also, it was near the end of a lengthy survey
instrument. Data from the three mailings of the
original survey were used. Responses to the first
two mailings (N = 504) were for primary theme
development, and responses to the third mailing
(N = 166) were for theme saturation purposes. Of
the 504 respondents who returned the first two
mailings, 148 did not respond to the item about
constraints and 15 indicated there were no constraints to their practice. Therefore, themes about
the constraints phenomenon were derived from
comments entered by 341 respondents. All of the
data that were reported were used although the
number of responses in some theme categories
were few. Other data sources were the investigators
theoretical memos and the literature.
Characteristics of the respondents. All sections of the United States including the District of
Columbia, Alaska, and Hawaii were represented in
the 44 states where respondents lived. Of those who
reported on highest degree earned, 90.3% (N = 306)
indicated they held a master's degree and 8%
(N = 28) reported doctoral degrees. It was not
surprising to find that 95% (N = 324) of the
respondents were women. Racial and cultural backgrounds included: 94.7% (N = 323) White, 2.3%
(N = 8) African American, 0.9% (N = 3) Asian
and Pacific Islanders, 0.6% (N = 2) American
Indians, and 0.6% (N = 3) of Hispanic ethnic
heritage. Other respondent and work setting variables are illustrated in Tables 1, 2, and 3.
As indicated in Table 1, the mean age of
respondents was 46.96 years. Those who reported
information about career time indicated a mean of
27.71 years worked in psychiatric nursing. Of those
years, 16.92 were spent at the basic level and 10.79
at the advanced level of psychiatric nursing prac-

Data Source
Respondents were certified psychiatric clinical
specialists listed by the American Nurses Association Credenfialing Center when data were collected.
Measures taken to ensure confidentiality and anonymity mirrored those taken for the larger study
and in addition included approval by a University
Institutional Review Board. Information about the
sample, survey instrument, and data collection has
been previously reported (SERPN, 1997).

Table 1. Means and Standard Deviations of Select


Respondent Characteristics
Variable

SD

Age
Years worked: basic Psychiatric
nursing
Years worked: advanced psychiatric
nursing
Hours worked per week: primary
setting

334

46.96

6.94

335

16.92

6.80

335

10.79

6.41

336

34.04

11.06

201

CONSTRAINTS TO ADVANCED NURSING PRACTICE

Table 2. Employment Setting of Primary Position


Setting

Frequency*

Percent

Hospitals
Clinics, Rehabilitation
Solo Independent
Academic
Group Independent
Visiting Nurse Association
Residential Setting
Other

100
78
57
43
32
9
8
9

29.8
23.2
17.0
12.8
9.5
2.7
2.4
2.7

*Frequency missing = 5.

tice (Table 1). The majority of the respondents


(72.4%) reported that they were employed fulltime, and the mean hours worked in the primary
setting each week was 34.04 (Table 1). In addition,
50% of the respondents reported they were employed in secondary settings and 54% indicated
they were on-call during off duty hours. Secondary
settings were similar to those listed in Table 2 for
primary employment. Median salary was in the
$40,000 to $49,999 range. Tables 2 and 3 show
where time was spent or positions for which salary
was paid for primary employment.
As revealed in Table 2, 53% of the respondents
worked in hospitals or clinics, whereas 26.5%
worked in group or independent practices. Far
fewer worked in academic, visiting nurse, or residential settings. As expected, position descriptions
were typical of the employment settings where
most of the respondents worked. Table 3 reveals
that 65.4% of the respondents worked as Clinical
Specialists or NPs, 7.9% as Program Directors or
managers, and 5.5% as hospital or staff nurses.

Data Analysis
Data analysis involved coding, classifying, and
conceptualizing all of the textual data for the
Table 3. Position Description in Primary Setting
Position

Frequency

Percent

Clinical Nurse Specialist


Nurse Practitioner
School of Nursing
Program Director
Manager
Nursing/hospital
Staff Nurse
Case Manager
Consultant
Staff Development
Researcher
Other

193
30
28
14
13
10
9
5
4
3
2
30

56.6
8.8
8.2
4.1
3.8
2,9
2.6
1.5
1.2
0.9
0.6
8.8

purpose of developing themes that explained the


constraints to practice phenomenon. Both inductive
and deductive strategies were used during the
cyclical data analysis process that was operationalized on three levels as described later. Within each
level of analysis, data were independently scrutinized at least twice and jointly analyzed at least
once for a minimum of 15 analytic reviews.
During the first level of analysis, each investigator examined the written statements from respondents about constraints to practice and independently developed initial categories. The second
level of analysis involved expanding the initial
categories and building new ones by deciphering
the meanings contained in complex statements.
Independently, each researcher broke down complex statements without altering them. Then slices
of data were either integrated into existing categories or put aside for development of new ones. As in
the first level of analysis, data bits were compared
for similarities and dissimilarities. Once all categories were saturated with the slices of data from the
simple and complex statements, the investigators
processed the data jointly according to guidelines
recommended for operational refinement (Lincoln
& Guba, 1989). Operational refinement delineated
the conceptual themes about constraints that are
listed in Table 4.
During the third level of analysis the data from
the third mailing of the survey (N = 166) was used
for theme saturation and refinement. Applying the
previously described exploratory techniques to these
data revealed no substantive additions to themes
already generated. As the final step, theme refinement involved: (1) exploring statements for conceptual meaning, negative cases, and number of respondents who had made statements about the specific
theme; (2) revisiting the literature; and (3) peer
debriefing.
RESULTS

Theme categories, number of statements that


formed theme clusters, and sample statements are
shown in Table 4. Collectively, the themes represented both constraints and barriers to practice.

Reimbursement
Statements about reimbursement formed one of
the largest clusters of data (Table 4). Both general
and specific types of reimbursement were identified. General types of reimbursement were "third

HOWARD AND GREINER

202

Table 4. Constraints to Advanced Practice Psychiatric-Mental


Health Nursing: Themes, Number of Respondents, and
Sample Statements
Theme

Reimbursement

197

Prescriptive
authority

54

Admitting privileges
Bureaucracy

13
81

Practice environment

81

Colleagues

84

Image

36

Personal

30

Sample Statement

"In my private practice many


people would like to see me and
their insurance won't pay."
"1 cannot prescribe medication. I
monitor and recommend to psychiatrists and family practice
doctors. They do not respect my
opinions or fail to medicate
when I suggest it."
"Legal and privileging issues preventing hospital admitting."
"'Politics/games of bureaucracy
inhibit creativity of clinical specialist who is resented as a
threat to the power systems."
"'It is frustrating to watch the ship
sink and not be able to do anything to save it."
"Refusal of psychiatrists and
some other health care providers to allow nurse practitioners into the area where 1 practice."
"'Relative invisibility of clinical
nurse specialists as a primary
provider to the consumer."
"The only other constraints are
related to my education and
experience."

party," "insurance," and "managed care." Specific


types of reimbursement were "Medicare" and
"Medicaid." Frequently the reimbursement constraint was described with such terms as "limited,"
"severely limited," "closed out," and "shut out."
More specific descriptions about the result of this
constraint included "inability to get into networks"; "lack of referrals because of no third party
reimbursement"; "difficulty attracting patients";
and "I turn away 50% because of refusal of
insurance reimbursement." The reimbursement constraint also had an impact on consumers: "Large
numbers of insurers do not reimburse clinical
specialists (CS); as a result we have to transfer pt.
(patient) to other providers, who are usually more
expensive."
Specific constraints. Comments about specific
constraints suggested respondents had "difficulty
getting contracts" and access to "managed care
panels," "HMO lists," and organizations "provider rolls." Specific comments about lack of
Medicare and Medicaid reimbursement were reveal-

ing. For example, one respondent wrote: "Unable


to see elderly Medicare patients in their home and if
I see them in the office I have to have a Psych MD
in the building because of Medicare regulations."
Reports suggested that some Medicare reimbursement constraints were linked to practice location:
"I have a gero-psych masters with 5 years experience in dementia assessment and care management
but Medicare does not reimburse me in medically
served area." Reports about Medicaid were similar:
"Medicaid will not pay me. I ' d be happy to work
with more needy clients in my practice, but cannot
be reimbursed."

Prescriptive Authority
There were 54 statements about Prescriptive
Authority (Table 4). These statements encompassed two areas of concern: (1) legal controls, and
(2) lack of protocols for prescribing medications
when there were no legal controls.
Legal control. In this study, legal control refers
to both complete and partial restriction of prescriptive privilege. Most statements were about complete restriction, and "Illegal to prescribe" was the
most frequent response. Comments about partial
restrictions contained specific information about
the types or classes of drugs that could not be
prescribed. Examples included: "controlled substances," "class III meds," "class IV controlled
substances," and "most drugs used in psychiatric
practice."
Some statements revealed information about a
specific type of control: "must consult and receive
prescriptions from physicians." Other comments
provided an even broader picture of advanced
practice and the prescriptive authority constraint:
"A very limited number of psychiatrists to refer to
for medication management who are able to treat
women with respect, dignity, and safe pharmacology."

Lack of protocols for prescribing medications.


The second cluster of statements in the Prescriptive
Authority theme revealed constraints that exist
even when there is no legal prescriptive barrier.
These constraints were related to lack of protocols
for prescribing in "private practice," "clinic,"
"hospital," and "outpatient" settings. Even though
settings varied, reports about protocol-related conditions were similar. Protocol-related concerns included: (1) their nonexistence, (2) their timeconsuming nature, and (3) problems associated
with collaborative aspects of procedures. Examples

CONSTRAINTS TO ADVANCED NURSING PRACTICE

of statements included: "hospital does not acknowledge prescriptive privilege of clinical nurse specialist (CNS) at this time"; "at present I am getting
prescriptive protocols through so that I can prescribe in outpatient setting"; and "the procedure is
time consuming and frustrating for me."
No statements disconfirmed patterns about legal
control and lack of protocols, although one statement, "I do not prescribe medication, my choice"
differed from other comments. Other respondents
reported concerns about the importance of psychopharmacology course offerings: "Although my
state recently gave CNSs prescriptive privileges,
the nearest psychopharm course offered is at least a
2 hour drive away."

Admitting Privileges
Only a few statements focused on lack of
admitting privileges (Table 4). However, this category of data was striking because responses
explicitly focused on a single characteristic of the
constraints theme. Admitting privileges--in and of
themselves--constituted a constraint to practice
whether they were controlled by legal or by hospital systems.
Most responses about the admitting privilege
obstacle were statements like: "Hospitals do not
offer admitting privileges," but other statements
provided a broader picture of the obstacle. For
example, one respondent reported:
As a hospital employee, I work under the hospital umbrella
for billing. I can not use my ARNP license because there
isn't enough physician back up or support. I also do not
have admitting privileges. It is frustrating not to be allowed
to utilize the clinical skill and knowledge I have studied
hard for. In private practice, insurance's (sic) will reimburse for ARNP services. But there are still restrictions
regarding admitting privileges.

As with the theme of Prescriptive Authority, one


statement suggested personal choice: "Don't have
admitting privileges to hospitals; don't want that
now." Although personal choice was the primary
focus of this particular statement, the other comments about admitting privileges were not about
choice. Rather they indicated that lack of admitting
privileges constituted a constraint to practice.

Bureaucracy
As indicated in Table 4, the theme of bureaucracy was organized around a large cluster of data.
Four characteristics of bureaucracies were embedded in the data cluster. They were (1) organization

203

types, (2) APPN utilization patterns, (3) limited


resources, and (4) paperwork overload.
Organizations. Comments about organizations
provided information about the setting, ideology,
and structure. Settings included "military," "governmental," "hospital," and "community-based
services." Words and phrases that revealed types of
stumbling blocks in the organizations included
"rules," "regulations," "lack of support," and "all
the constraints associated with a state-run facility!"
Workplace ideology was embedded in words and
phrases that suggested certain managerial styles or
approaches. Examples included: "administrative
edicts," "administration attitude," and "administrative demands (irrelevant meetings, etc.)." Ideology
was also described in terms of the predominant
model of organizations: "work within the medical
model"; "work within a traditional medical setting
so treatment focus on illness vs. health maintenance"; and "limited focus placed on preventive
mental health." Finally, there were statements that
revealed ideology about advanced practice nursing,
best summarized with the following comment:
"many constraints within a system that has difficulty utilizing a person with advanced degree
functioning as a staff nurse."
Constraining organizational structures were also
reported, usually in terms of job descriptions and
reporting relationships. An example of the former
was: "Presently the constraints I have are imposed
by the job description as written by the State with
whom I am employed. I do not do physical
assessments formally, except in my role as a
nursing consultant nor do I write medical orders-hospital policy." Examples of constraints imposed
by reporting relationships in job structures included
"Immediate supervisor fails to provide support"
and "reporting relationship and salary is to Department of Nursing consequently limited # (number)
of pts--3 maximum--that I can carry in present
position."
APPN utilization patterns. Although some of
the above statements suggested utilization pattern
problems, others were more specific. The following
statement revealed information about under-utilization in a State system: "In my State, advanced
practice nurses are not included as providers in
categorical funding, it's like we don't exist." Comments about under-utilization in other systems
included: "Politics/games of bureaucracy inhibit
creativity of clinical specialist." Over-utilization
patterns were reported in terms of responsibilities,

204

caseload, and workload. Examples included: "responsibility is similar to the psychiatrist role w/o
(without) the remuneration"; "lots of responsibility without authority, formal positional power and
or legal ability to provide certain services"; "caseload too large"; and "lay-offs at hospital caused
increased work load for me of a supervisory-type
not yet in my job description."
Limited resources. Responses indicated that
fiscal and human resources were scarce. Limited
fiscal resources were reported in both specific and
general terms. The specific situations concerned
salary and "fee scales." The more general comments focused on global funding issues: "financial
funding concerns as monies dry up, every year
worrying about contracts and grants." Comments
about constraints on human resources included
"limited staffing" and "lack of secretary personnel." Limited fiscal and human resources had
implications for patient care as well as practice
patterns: "difficulty doing direct patient care and
documenting with fast pt. (patient) turnover and
limited staffing."
Paperwork overload. As indicated in the above
response, the quantity of paperwork was a constraining factor in practice. "Paperwork, paperwork,
paperwork" was the single comment of one respondent. Terms like "overwhelming" and "endless"
were used to describe the overload. Specifically,
paperwork was associated with requirements of
"managed care" and Medicaid." In general, the
constraint was best summarized as: "Too much
paperwork which detracts from the joy of helping
patients."
Practice Environment
Respondents spoke less precisely about ways in
which clients themselves and the society in which
we all live are experienced as constraints to practice. The practice environment was described in
terms of the client's economic and health status,
suitable interventions, and pressure to get the job
done.
Clients and interventions. Statements about
economic status included: "many clients have few
resources and many problems to cope with"; "poor
individuals without insurance who do not qualify
for Medicaid"; and "the economic level of patients: housing issues, transportation issues, family
support, overall health." Specific statements about
health status noted: "wide variety in age and
diagnosis," "very ill clients," and "increasing

HOWARD AND GREINER

severity of mental illness in my caseload." Respondents' comments further suggested that certain
interventions may not fit patient populations or that
suitable options for intervention were completely
lacking. Comments included "increasing focus on
brief treatment not suitable for chronic mental
illness" and "difficulty finding treatment options
for chronic alcoholic patients." The overall picture
was summarized by one respondent as: "unclear
mission with too much diversity in patient needs
within the treatment setting."
Time. A society that emphasizes speed, efficiency, and cost containment poses particular challenges to working with these complex economic
and health issues. A constraint for many respondents was "time." Although most respondents
simply entered the word "time" as a constraint,
other expressions included "time--never enough,"
and "I don't have time to do it all." Still others
explained specifically how lack of time influenced
the practice environment. Examples were: "too
busy for good follow-up care," and "time--often
there are several psychiatric patients in a busy
medical ER and there is tremendous pressure to do
the work quickly." The effect of time was also
embedded in comments such as "not enough hours
and energy in a day" and "time, too many ideas and
not enough time."
Colleagues
The theme of colleagues (Table 4) contained the
second largest cluster of data (N = 84). Respondents' comments suggested control issues. For this
study control is defined as lack of support for, or
failure to foster, the functions of advanced practice
nurses. Colleagues identified in the responses were
"physicians" and "other disciplines," which included "mental health providers," "administrative
staff, nonnursing," "LCSWs [licensed clinical social workers]," "psychologists," and "peers" in
nursing. As revealed in the description that follows,
types of constraints were related to specific colleague categories.
Physician-related constraints. Some of the
statements about physician-related constraints were
about the medical system: "lack of recognition of
CNS by physicians," "conservative medical community," and "national medical lobby." Respondents also reported on specific types of medical
systems: "Dept. of psychiatry is not a strong
service and the residents are generally not encouraged to work collaboratively with psych CNS as

CONSTRAINTS TO ADVANCED NURSING PRACTICE

the scope of our practice has expanded." However,


most reports were about physicians in the practice
setting, and the most frequent constraint reported
was "having to work under supervision of physician." Other comments included: "difficulty communicating with physicians," "need for willing,
cooperative, available and patient agreeable psychiatrist for back up," "finding MD willing to collaborate," and "some psychiatrists don't want to consult or even recognize services."
In essence this cluster of data supported the
comment: "lack of recognition of CNS by physicians." These data also supported the previously
described admitting and prescriptive authority
themes. For example, one respondent reported:
"Most of my work (Medicare, Medicaid) must be
supervised by MD. I often have to rely on 1st year
psych residents to admit my patients or write
scripts and they often question my judgement and
feel uncomfortable serving in this role when, in
reality, I have a better grasp of the situation."
Perhaps the following comment best summarized
physician-related constraints: "refusal to allow
nurse practitioners into area where I practice and
other nearby areas. The psychiatrists don't live
within a 350 mile radius of us, it costs to get to
where they are, plus their fees are prohibitive."
Constraints related to other disciplines. Many
of the words and phrases used to describe physicianrelated constraints were also used to describe those
associated with other disciplines. Specific comments about other disciplines were: "encroachment
by LCSWs"; "this culture is more supportive of
LCSW and psychotherapists"; and "inadequate
liaison/outreach efforts by other community professionals including school teachers, social workers,
and probation officers." "Lack of support," "limited collaborative practice," and "other professionals do not think of me or remember me as a
provider" enhanced understanding about this constraint. Some comments revealed controls associated with nursing colleagues: "peers rigid and
close out newcomers" and "lack of support within
the profession." An effect of all these constraining
relationships was imbedded in the following statement: "territorial jealousy by other disciplines
prevents reinforcement of excellence in practice."

Image
Several respondents (Table 4) indicated that the
general public's image of nursing is a constraining
factor because conceptions and impressions about

205

roles and functions of nurses in psychiatric-mental


health practice remain unclear. Even though the
survey question addressed advanced practice, responses provided a glimpse of the general public's
view of the basic nursing role: "people still have a
limited view of nurses." Stereotypically, nurses
work in hospitals, not independently in community
settings. Respondents' comments indicated that the
advanced practice role was even more mysterious:
"It is difficult for them to relate/understand the
advanced role that is autonomous, and shows initial
thinking to the level used by myself. Some see me
just as a nurse, some see me just as a therapist. It is
hard for them to incorporate the two roles--I am
always teaching and educating others." The profession's responsibility in defining itself is clear. In the
words of one respondent: "This is a problem in our
field of not differentiating levels of RN practice,
i.e., ADN, BSN, MSN."

Personal
Although few in number (Table 4), some respondents reported personal constraints. These constraints involved self-regulation and self-limitations. Self-regulation refers to the establishment of
personal boundaries; self-limitations refer to personal characteristics, energy, and health.
Self-regulation. Most self-regulation responses
were about protecting personal lives. One typical
example: "I am unwilling to regularly work evenings or weekends. This constrains the mix of my
caseload as couples and families often require
evening or weekend appointments." A different
self-imposed boundary involved taking a stand
based on a personal ethical decision: "Will not
work with managed care, have not been pursued as
managed care employee and I am too concerned
about ethics of the care they provide for me to
pursue them."
Self-limitations. Most statements about selflimitations concerned lack of "education and experience." Several respondents reported lack of education in networking skills: "My training did not
allow for adequate networking to develop referral
services. As a result, 80% of my patients are very
low income without insurance." Additional education deficits included "training for private practice," "psychopharmacology," "physical assessment," and "education/supervision in rural setting."
Uncertainty about career direction posed a related
form of limitation: "not so clear about where I want
to go from here; find private practice isolating;

206

would like to resume PhD work but not sure in


what direction."
Discussion

Regulatory barriers, market-based constraints


and barriers, and inter/intraprofessional constraints
were clearly evidenced in this data. Rethinking
usual practices in relationship to them is imperative. Identifying specific needs for autonomous
practice, for collaborative efforts, and for focused
political action is the task. Suggested action is
outlined later under "implications."
Barriers to APPN practices. Both regulatory
and market-based barriers are implicated in the
reimbursement, prescriptive authority, and admitting privilege issues constraining the nurses. Statements about reimbursements formed by far the
largest category of response in this study (see Table
4). Although the numbers of respondents who
mentioned prescriptive authority and admitting
privileges were relatively small, 54 and 13, they are
nonetheless very specific indicators of future expectations regarding APPN practices. Even as regulatory barriers have begun to break down (Pearson,
1995), market-driven reimbursement barriers have
gained power to control all forms of nursing
practice, and very specifically, advanced practice.
As this shift is occurring, market forces potentially
dictate not only how we practice, but whether we
practice at all.
Increasingly, the exact services provided must be
made explicit if reimbursement is to occur. Making
our practices explicit is therefore imperative. For
example, assessing and prescribing routine medications, particularly in the care of people with serious
mental illness, is well documented as a service
competently provided by APPNs (American Nurses
Association [ANA], 1994). Where legislative barriers to prescriptive authority exist, political action is
required to remove them. As legislative barriers
break down, APPNs must be prepared to provide a
common set of services, including psychotropic
medication prescription, as a baseline.
A continuing struggle between resisting external
barriers and recognizing personal, sometimes selfimposed constraints is evident from these data. The
legislative barrier that prohibits prescriptive authority is clearly identifiable. A less well-defined set of
marketplace barriers has been rapidly developing.
Among these, the easiest and most effective barrier
to lift is the one that denies admitting privileges.

HOWARD AND GREINER

The nature of a practice with severely mentally ill


people will at times necessitate quick, brief admissions for stabilization. APPNs providing community-based care must have such access. Moreover,
the characteristics of respondents to this survey
(Table 1) suggest that certified APPNs are educationally and experimentally prepared to make judgments about the need for admission to an inpatient
setting, and the literature confirms that they are
capable of achieving good outcomes in client care
(Baradell, 1995; Merwin & Mauck, 1995). Models
also exist for estimating the cost of underutilization of APNs (Nichols, 1992). Such data are
imperative for influencing decision-making groups
at the facility level, at the reimbursement level, and
at the legislative level.
Constraints and barriers. Issues of working
with colleagues and in bureaucracies intermingle in
ways that cloud the identification of constraining
situations that could be changed. Individuals in this
study were plagued by constraining organizations
and specifically expressed distress at being underutilized. Bureaucratic practices continue to be
described by the APPNs as constraining clinical
practice. Organizational structures, utilization patterns, limited resources, and paperwork overload
were all named. This theme of external barriers
continues a very old story in nursing. If it is
dismissed as just that, however, an opportunity to
seize energizing possibilities will be lost. In this
context, it is important to remember the age
(mean = 47 years) and length of time in generalist
(mean = 17 years) and specialist (mean = 11 years)
practice of the nurses who participated in this
survey. In the current and anticipated practice
environments, the need for a shift to earlier specialization is strongly indicated.
Words by Aiken (1995) suggest other steps
nurses can take individually. Aiken (1995) discussed the phenomenon of nurses loving their work
but hating their jobs. Her work on utilization leads
her to proclaim that the time is right for transforming the nursing work force in such a way that the
imbalance between generalist prepared and advance practice nursing would be righted. She and
other colleagues have shown that reform at the unit
level can occur in hospitals without unusual top
leadership. Organization of nursing, even at the
unit level, that results in greater autonomy makes a
huge difference (Aiken, Smith, & Lake, 1994).
Again, APPNs prepared to provide and actually

CONSTRAINTS TO ADVANCED NURSING PRACTICE

providing a common set of services has the potential for communicating a powerful and different
message to administrative personnel at all levels of
the bureaucratic system. Nurses who practice in
routine staff level positions within hospitals, yet
identify themselves and their preparation as APPNs, contribute to the confusion regarding who we
are and what services we can offer. This form of
under-utilization seems to be most prevalent within
hospitals. Although primary care settings are not
without bureaucratic barriers and constraints, they
do have the advantage of making autonomous
practice visible. Primary care settings are also less
likely to employ APPNs in positions that do not
require their advanced practice skills.
The ways in which the respondents to the
SERPN survey discussed issues related to colleagues also echoed very old stories in nursing,
even as they suggested specific attainable remedies.
Effective collaborative relationships with physicians and other health care providers are imperative
to effective APPN practice. Models of collaboration that reflect clearly defined practices with
effective therapeutic and cost outcomes do exist
(Saner & Ford, 1995). The numbers must be
multiplied dramatically.
Although personal responsibility for professional relationships is important, cultural and professional realities continue to reinforce physician
control. A serious error is made when nurses
continue to focus only on the personal level and fail
to recognize the larger political issue inherent in
physician control. Naming providers only as "nonphysicians" renders whole groups of potential
providers culturally invisible (Friedman, 1990;
Safriet, 1992, 1994).
Legislation mandating physician supervision of
APPN practice obscures those areas in which
scopes of practice overlap. Multiple groups must
work collaboratively toward development of competency-based practice acts, interdisciplinary education programs, revised payment schedules, and
practice law that allows demonstrably competent
providers to diagnose, treat, and prescribe (Safriet,
1994).
Intraprofessional and personal constraints. To
engage in political action collaboratively, work
within nursing is obvious. Educationally, the set of
APPN standards (ANA Council on Psychiatric and
Mental Health Nursing, 1994) must be used to
guide practice evaluation that show effective clini-

207

cal interventions whereas education standards and


competencies for graduates developed by our national organizations (SERPN, 1996; ANA, 1997)
must be used to refine and develop programs. It is
equally important to pilot new curriculum guidelines like those recommended for behavioral health
care to determine their effectiveness for emerging
systems (ANA, 1997). Clients' and employers'
expectations of nursing services will develop and
create a clear demand for these services only if
nurses reliably demonstrate an identifiable set of
competencies based on these types of standards and
models of care. Additionally, as prescriptive authority becomes a reality, standardized academic preparation to assume prescriptive responsibility based
on existing guidelines (ANA, 1994) that are continually refined is indicated.
Organizationally, the Coalition of Psychiatric
Nursing Organizations (COPNO) has an increasing
responsibility for identifying strategies for effective
legislative change and marketplace inclusion for
APPNs. Joining with nurse practitioner organizations to continue the delineating of Advanced
Practice Nursing has the potential for advancing
these objectives. The history of the clinical specialist in psychiatric nursing is similar to the history of
master's-prepared nurse practitioners in regard to
strong clinical skills and the potential for autonomy
in their practices (Cronenwett, 1995; Fenton &
Brykczynski, 1993). The challenge is to keep both
common ground and specialty expertise in focus as
multiple groups join in collaborative efforts to
eliminate barriers to competent practices.
Incremental approaches to educational preparation, great variety in practices, and multiple titles
are all covered by the umbrella term "nurse."
These facts continue to obscure the possibilities of
APPN practice, of all nursing practices. Nursing
has allowed for an enormous range of practices,
especially within psychiatric nursing, where creativity and difference have been embraced as a great
strength. The differences may obscure an easily
understood common core of competent practices.

Implications
As specialists within nursing, APPNs must make
their services explicit. This imperative pertains
regardless of practice setting. Data from this study
suggest that making exact services explicit is most
vitally needed in inpatient settings. The current
document (ANA Council on Psychiatric Mental

208

HOWARD AND GREINER

Health Nursing, 1994) that combines the original


two earlier documents is extremely valuable. To
maintain currency of such a document requires
continuous effort at the national level. Standard
academic preparation for assuming prescriptive
responsibility must be refined to prepare APPNs for
future practice imperatives.
Developing separate strategies for changing legal and market-driven regulations is required. For
example, ease of access to short-term hospital care
for clients is needed. In many inpatient settings
privileging is primarily a market-driven activity. As
APPNs anticipate providing a relatively standard
set of services, securing hospital admitting privileges is one way to exercise control over access and
in many settings can be influenced by a single
APPN. Legislative reform requires strategic collaboration within nursing, specifically with all other
advanced practice nurses. Prescriptive authority is
one small aspect of a larger goal of competencybased practice acts. To reach this goal interprofessional collaboration is essential.
In approaching collaborative work, nurses continue to learn about the importance of naming
themselves as they make explicit the services they
provide. Naming requires unequivocally stating
who nurses are rather than allowing definitions
such as "nonphysician provider" to continue unchallenged in official statements. Naming also
requires a unanimity of purpose within nursing.
The body of research on therapeutic and costeffective outcomes of service must grow. Existing
data on effective utilization of all advanced practice
nurses can make dramatic differences in a marketdriven health care system. Individually and in
strategic efforts at the national level we are challenged to access and translate those data to eliminate barriers to providing care to people with
mental illness.
SUMMARY
This study describes constraints to practice as
reported in a national survey designed to describe
advanced practice in psychiatric nursing. Thematically, the nurses described both constraints and
externally imposed barriers to practice. The identification of legislative and market-driven barriers,
collegial and bureaucratic constraints and barriers,
and interdisciplinary constraints differentiate specific personal and organizational directions for
action.

ACKNOWLEDGMENT

The authors acknowledge Rouald W. Manderscheid, PhD


from the US Department of Health and Human Services-Center for Mental Health Services, and the comembers of the
SERPN Task Force who conducted the national survey: Lorna
Mill Barrell, PhD, RN; Margery Chisholm, EdD, RN, CS;
Jeanne Clement, EdD, RN, CS; Kathleen R. Delaney, DNSc,
RN: Elizabeth Merwin, PhD, RN; Elizabeth C. Poster, PhD, RN.
Research Assistants who contributed to the study about constraints were Sanggil Kim, MSN, RN and Jennifer Roth Parr,
MSN, RN of the University of Kentucky College of Nursing.
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