Embracing the challenges in graduate geropsychiatric nursing education: Findings from a national survey

Introduction

Advanced practice nurses are relied upon to build a culture of health (Robert Wood Johnson Foundation, 2017) for the 7.5 million older persons with mental illness (Evans, Buckwalter, & Beck, 2015; John A. Hartford Foundation, 2011). In 2030, the population of older persons is expected to nearly double (Ortman, Velkoff, & Hogan, 2014) and result in a simultaneous 80% increase in the number of older persons with mental health and substance use disorders (Institute of Medicine, 2012). Filling the gaps in geriatric mental health with education and collaborative practice opportunities are among the looming challenges that currently face colleges of nursing (Stephens, Harris, & Buron, 2015).

Over the past ten years, there have been significant demographic, academic, and practice changes. These changes warranted a national survey that was conducted in 2014 on graduate nursing programs (Stephens et al., 2015) to evaluate the state of geropsychiatric nursing (GPN). The purpose of this paper is to investigate and report additional findings and perspectives from these survey results to answer three research questions. What are the 1) barriers, 2) institutional desires, and 3) awareness of resources that can be used to propose solutions for advancing graduate nursing education and collaborative practice in GPN?

Background

Graduate geropsychiatric nursing

From a nursing perspective, graduate nursing education is founded on a competency-based approach within the framework of the APRN Consensus Model (APRN Joint Dialogue Group, 2008). Graduate GPN is aligned with nursing and interprofessional competencies in education and collaborative practice (Association for Prevention Teaching and Research, 2009; Harris, Mayo, Balas, Aaron, & Buron, 2013). Although there is no certification in geropsychiatric nursing, nurse practitioners and clinical nurse specialists can specialize in psychiatric mental health, adult-gerontology primary care or acute care nursing and further subspecialize in geropsychiatric nursing.

Nurse educators have been tracking the progress of GPN since 1985. Thirty years ago, higher education was more focused on gerontology rather than geropsychiatry.

The first national survey (Murphy & Hoeffer, 1987) showed that half of psychiatric mental health nursing programs provided a subspecialty and the remaining programs allowed students to choose a specific population for their clinical experiences. The survey results indicated that GPN had a high potential for program growth as a subspecialty. In 1993, a questionnaire (Hoeffer, 1994) evaluated essential graduate level gerontological nursing knowledge, competencies and GPN.

In 2004, researchers from the University of Pennsylvania conducted a survey on graduate geropsychiatric nursing education (Kurlowicz, Puentes, Evans, Spool, & Ratcliff, 2007). Results showed that one third of psychiatric mental health nursing graduate programs (n=60) reported some GPN content. Over half (n=116) of all the schools responding to the survey (n=206) reported integration of GPN content. Most GPN content was found in graduate nonpsychiatric programs rather than psychiatric mental health programs.

A survey in 2014 (Stephens et al., 2015) compared with the similar survey 10 years earlier (Kurlowicz et al., 2007) found that despite substantial efforts to improve GPN education, fewer than 70% of nursing schools offer GPN content. Moreover, only 40% of APRN primary care programs include GPN content in their curricula, and fewer than 9% of nursing schools provide specific GPN programs, tracks or minors (Stephens et al., 2015). The 2014 survey, and results from the two previous national surveys have captured 28 years of trends in GPN (Hoeffer, 1994; Kurlowicz et al., 2007; Stephens et al., 2015).

All data in this study are from the 2014 national survey with additional information to improve geriatric mental healthcare (Stephens et al., 2015). The analysis in this study is a response to the survey questions in Table 1. The results inform: 1) Educators with further information to include in graduate nursing programs and 2) Policy makers with recommendations for bolstering the geropsychiatric workforce.

Table 1.

Selected geropsychiatric graduate nursing education survey questions.

Geropsychiatric nursing educational resources	Responses
Does your institution use the Geropsychiatric Nursing Competency Enhancements? http://www.pogoe.org/productid/20660	Yes No Unsure I didn’t know the resource existed
How often does your faculty utilize the geropsychiatric nursing content on POGOe? http://www.pogoe.org/	Not at all Somewhat Quite a bit All the time Unsure I didn’t know the resources existed
How often does your faculty utilize the geropsychiatric nursing content on consultgerirn? http://consultgerirn.org/	Not at all Somewhat Quite a bit All the time Unsure I didn’t know the resources existed
How often does your faculty utilize the geropsychiatric nursing content on Geriatrics at Your Fingertips? http://geriatricscareonline.org/ProductAbstract/geriatrics-at-your-fingertips/B005/	Not at all Somewhat Quite a bit All the time Unsure I didn’t know the resources existed
What other geropsychiatric nursing web-based resources does your program use?	Please specify Responses
What funding support (federal, foundation, etc.) has your program received for geropsychiatric graduate nursing education?	None Current Previous Don’t know
Please indicate ALL types of funding sources you have received for GPN graduate education	HRSA Foundation State Funding Other I don’t know If you marked other, please specify
Geropsychiatric graduate nursing education: desires and barriers	Responses
Does your school DESIRE to have a subspecialty clinical track or minor in geropsychiatric nursing?	Yes-we are actively working on it Yes-we have considered it Unsure No-it is not a priority at this time Don’t know
What is the primary barrier to implementing a subspecialty clinical track or minor in geropsychiatric nursing at your institution?	Lack of student interest Not enough time in the program Not very important content relative to the other topics we need to cover Lack of faculty expertise No funding to support the program Unsure
Interprofessional education	Responses
Is there an interprofessional education component or focus in your graduate nursing education programs?	Yes No
If yes, describe the nature of your interprofessional education as it relates to the care of the older adult with psychiatric mental health issues
What disciplines are involved in your IPE as it relates to the care of the older adult with psychiatric mental health issues? Please select all that apply	Nursing Medicine/Psychiatry Pharmacy Physical Therapy Dentistry Social Work Other Don’t know

Methods

Participants

A more detailed description of survey development and methodology has been previously described (Stephens et al., 2015).

In November 2013, electronic invitations were sent to U.S. accredited schools of nursing (n = 363) with advanced practice registered nursing programs asking the person most responsible for graduate nursing programs to complete an internet-based survey questionnaire. The survey was adapted from the 2004 Graduate GPN Survey (Kurlowicz et al., 2007) and was modified to reflect recent changes in the APRN Consensus Model, advanced practice nursing programs, resources, faculty, and other changes. Topics added to the survey included programming and barriers to implementation, preparation of faculty to teach GPN content, as well as the integration of content in didactic and clinical settings. The Carnegie Classification™ (http://carnegieclassifications.iu.edu/), the leading framework for recognizing and describing institutional diversity in higher education, was used to determine each nursing school’s parent institution and geographic region. Consistent with prior studies (Kurlowicz et al., 2007; Stephens et al., 2015), this framework was used as a method for controlling for institutional differences to ensure adequate representation of sampled institutions, students or faculty. The study received approval and exemption by the Institutional Review Board at the University of Arkansas for Medical Sciences.

Study design

Six gerontological or GPN experts reviewed the survey for content validity. The survey included a total of 102 Likert scale, multiple choice, ratio, and some open-ended questions. The survey was entered into REDCap data management system at the University of California at San Francisco.

Survey procedures

The study was electronically disseminated to Deans of accredited graduate nursing institutions. The Deans directed the survey to the most appropriate person who was responsible for the program. The study closed in 2014 and yielded a 56% response rate (n = 202).

Members of the research team removed duplicate surveys. The data were reviewed and coded. Team members were blinded to the institution and examined conflicting responses with 100% consensus on data coding.

Statistical analysis

Descriptive statistics were used to describe the characteristics of the participating schools of nursing reporting a GPN, track or minor. Frequency, percent, and measures of central tendency were calculated on each categorical survey question. Cross tabulations were used to describe the pattern of responses across questions. Chi-square tests were used to evaluate any difference in Carnegie or geographic regions (Stephens et al., 2015). STATA (StataCorp, 2013) was used to perform the analyses.

Results

The institutional role of the respondents completing the survey varied. Responses by program directors ranged from 18.3–16.2% including Adult-Gerontology Nurse Practitioner and/or Clinical Nurse Specialist Program Directors, Family Nurse Practitioner Program or Psychiatric Mental Health Program Directors. Women’s Health respondents accounted for 0.7% of program directors. Some Deans (6.3% and Associate Deans 9.2%) also responded. The majority of the responses were received from participants outside these roles (31.7%).

There were no statistically significant differences in Carnegie ranking between respondent and non-respondent schools.

Of the 202 responses to the web-based survey, schools of nursing reported the barriers to increasing GPN content including lack of institutional and external funding to support the program (47.2%), lack of faculty expertise (31.3%), and lack of student interest in GPN (29.9%). Almost 80% of schools reported that they have not received any funding to support GPN graduate education. For those schools with current (7.1%) or prior funding (8.2%), funding from Health Resources and Services Administration (HRSA) was the primary source (85.2%), followed by foundation/private grants (29.6%), state funding (22.2%) and other sources (7.4%).

Approximately one third of schools reported having a PhD or Master’s prepared nursing faculty member with GPN expertise teaching in their clinical programs. Outside of the nursing discipline, the most common clinician preceptors identified as teaching GPN content were: psychologists (24%), followed by geriatricians (29%) and psychiatrists (24%).

In terms of GPN resources utilized by faculty, only 25% of schools reported using the GPN Competency Enhancements and 44% were unsure or did not know they existed.

Fewer than 12% of the respondents regularly used the GPN resources on the Portal of Online Geriatric Education (POGOe) website and 37% were unsure or did not know that POGOe GPN resources existed. Fewer than 18% of participants regularly used the GPN resources on the ConsultGeri website, however over 60% were not using or did not know these resources existed. Over 55% of nursing programs reported not using or did not know about Geriatrics at Your Fingertips as a resource for GPN in their programs.

Of the schools not offering a GPN program, track or minor (n = 132), 53% reported it was not a priority at this time, while another 27% were unsure whether it was a desire of their institution. Less than 5% were actively working on creating such a program.

Discussion

Recognizing barriers to graduate GPN education is the first step in ensuring adequate preparation of graduate nurses as members of the interprofessional geropsychiatric workforce. This survey identified three barriers to successful expansion and implementation of graduate GPN education: 1) lack of funding, 2) lack of faculty preparation, and 3) lack of institutional desire for GPN program, track, or minor into the curriculum.

Funding opportunities are key to advancing GPN education, but scarce in GPN programs and accessed by very few schools. Lack of funding was identified as a barrier in the early days of curricula development in GPN (McBride & Burgener, 1994). The Health Resources and Services Administration (HRSA) has a special interest in GPN education and actually supported part of this current study. The importance of HRSA grants in the development of graduate GPN cannot be overstated. Foundations such as the John A. Hartford Foundation supported the Geropsychiatric Nursing Collaborative to educate nurses and improve the mental health of older Americans. The Hartford Foundation is another primary funding source. Other foundations such as the Gerontological Advanced Practice Nursing Foundation and American Association of Colleges of Nursing are also supportive of GPN education (Evans et al., 2015). Nevertheless, it is evident that educators and policy makers need to advocate for much greater GPN funding allocations to adequately train the workforce to meet the mental health needs of the growing population of older persons.

Lack of faculty preparation was identified in the survey as another significant barrier in GPN education. Again, the need for faculty development is as important in contemporary GPN education as it was in the early days (Mayo, Harris, & Buron, 2016; McBride & Burgener, 1994). The lack of awareness of common resources such as ConsultGeri, Geriatrics at Your Fingertips, and POGOe reflect the inadequate level of preparation of faculty in GPN education (Melillo, 2017). Graduate nursing students clearly need faculty, preceptors, and mentors to guide knowledge and clinical experiences that focus on the assessment, diagnosis, and treatment of late life depression, schizophrenia, bipolar disorder, substance misuse, and dementia.

This survey further identified faculty overall unfamiliarity with the Geropsychiatric Nursing Competency Enhancements that are housed on POGOe. While contemporary GPN is built upon the Scope and Standards of Gerontological Nursing Practice and the Scope and Standards of Psychiatric Mental Health Nursing Practice, these Competency Enhancements (Batchelor-Aselage, DiMeglio, Aaron, & Duggar, 2014; Beck, Buckwalter, & Evans, 2012a, 2012b; Mayo et al., 2016) were developed to augment existing competencies. They were then strategically integrated into curricula across graduate nursing programs in 2010. Given the changes brought about with the APRN Consensus Model (APRN Joint Dialogue Group, 2008), these resources were timely and completed gaps across graduate nursing programs (Melillo, 2017). Unfortunately, many faculty are still unfamiliar with this rich resource. Thus, continuing education is needed to further increase awareness and urgency of faculty responsibility for the full implementation of the Geropsychiatric Nursing Competency Enhancements into curricula.

In order to further GPN academic education and awareness, other continuing education opportunities are also needed (McBride & Burgener, 1994). For example, the National Hartford Center of Geriatric Nursing Excellence, the Hartford Institute of Geriatric Nursing, and the American Association of Colleges of Nursing recently partnered to form the Geropsychiatric Nursing Initiative (GPNI). The GPNI recognizes the need for dedicated resources for GPN and has developed online learning tools to support GPN graduate education and nursing faculty development. These online learning opportunities and faculty resources can be found on the ConsultGeri website. Active engagement with specialty organizations is critical to further increasing awareness and dissemination of these valuable resources.

Coupled with the lack of faculty preparation, the survey showed a possible lack of desire for incorporating a GPN program, track, or minor into graduate education. The survey question addressing institutional desire was stated directly and unique to this 2014 survey. It is not clear, however, whether the lack of institutional desire is primarily due to lack of capacity, lack of resources and/or lack of student interest or all of the above.

To that end, it is important to recognize that GPN is a subspecialty that addresses the mental health needs of older persons. However, no specific GPN certification currently exists (Melillo & Hoff, 2011). Today, specialization in GPN occurs within the context of family, psychiatric mental health, gerontology, or adult-gerontology advanced practice nursing roles. The complementary overlap and natural blend of geriatrics and psychiatry in the clinical nurse specialist and nurse practitioner roles are unique strengths of the nursing profession (Morris & Mentes, 2006). However, GPN is a subspecialty that fits within the APRN Consensus Model (APRN Joint Dialogue Group, 2008). A subspecialty certification recognizes the preparation of advanced practice nurses (Melillo, 2017). Without subspecialty certification and the requisite numbers of expert GPN faculty, student desires cannot be cultivated and the workforce cannot be developed. Passionate GPN leaders and advocates are needed to accelerate the Subspecialty GPN Certification.

Finally, although the survey identified the above needs for faculty development, it also found that psychiatrists, psychologists, and geriatricians are actively engaged in interprofessional education and collaboration in graduate nursing programs. This is a promising finding. GPN is inherently a collaborative model and was introduced into interprofessional education almost 40 years ago (Beck, Buckwalter, Dudzik, & Evans, 2011; Harris et al., 2013). Historically, however, the interprofessional education focus has largely been at the undergraduate nursing level. Mounting evidence suggests that graduate nursing education interfaces with successful collaborative practice teams to provide the highest quality care and excellence in geriatric mental health (Mayo et al., 2016; Harris et al., 2013; National Center for Interprofessional Practice and Education (NCIPE), 2015; Miller, Kessler, Peek & Kallenberg, 2011). Thus, interprofessional education and collaboration is a place to continue cultivating relationships with experts who will model collaboration and foster the interprofessional role development of future geropsychiatric advanced practice nurses.

Limitations

There are several limitations to this study. Respondents may inject bias into responses due to affiliation with the institution. Some respondents who are overseeing but not teaching in the program and who are not experts in GPN may be unaware of fine details associated with GPN resources and where to find them. Although it has been over ten years since the last national survey on GPN graduate education, newly developed programs may not have enough time to fully adopt and implement changes.

Conclusion

Over the last ten years, there has been little change in the numbers of schools reporting GPN content in their graduate clinical programs or offering a GPN subspecialty (Stephens et al., 2015; Kurlowicz et al., 2007: Hoeffer, 1994). Throughout the years, history is repeated. The same barriers persist for meeting the mental health needs of the growing older adult population, including the lack of funding, faculty preparation, and lack of strong support for GPN education.

Doctorally prepared nurses must take the lead in securing federal and other sources of funding to enhance graduate GPN education. Nursing faculty also need to seek opportunities to gain knowledge through continuing education and other resources to become champions for GPN. Other challenges for success include finding appropriate clinical sites, training of clinical preceptors with expertise in mental health of older adults, and maximizing opportunities to participate in interprofessional education (Beck et al., 2012a, 2012b; Harris et al., 2013).

The Future of Nursing Report (Institute of Medicine, 2010) supports the unique role of advanced practice nurses as members of the interprofessional team to transform mental healthcare for older persons. Hoeffer (1994) identified the need for interprofessional education and collaboration in GPN as part of the graduate nursing curricula. Opportunities for Interprofessional education and collaboration in geropsychiatry are just as vital today. Planned, systematic, and intentional topics, simulations and experiences on geropsychiatry go hand-in-hand with faculty preparation. Organizations such as the American Geriatrics Society, American Association of Geriatric Psychiatry, Gerontological Society of America, and Gerontological Advanced Nursing Association are just some of the organizations providing resources and guidance for interprofessional education and practice.

It is an exciting opportunity for APRNs to make a difference in the mental healthcare of older adults. The need for GPN experts is undisputed. A strong model of graduate nursing education promotes an expert, well-qualified GPN workforce. Graduate GPN education holds the promise of optimal mental health for older persons.