Subspecialty development in nursing is reviewed and an overview of curricula designed to meet the educational needs of the geropsychiatric clinical nurse specialist is presented. Individual and group supervision is set forth as an essential component of the clinical practicum, and various settings with specific role options for the geropsychiatric clinical nurse specialist clinical practicum are outlined. The option of gaining clinical practicum experience with a special population in the geropsychiatric community also is addressed.
The emergence of a subspecialty in the field of nursing mandates a systematic approach toward developing curricula that meet the educational and experiential needs of students. 1956, at the National Working Conference on the Education of the Clinical Specialist in Psychiatric Nursing (Kuntz, 1980). The clinical nurse specialist role was new to the field of nursing. It was seen as a role that was integral to the “revolution” and “evolution” of the nursing profession (Kuntz, 1980; National League for Nursing, 1958).
At the inception of the specialty, it was expected to evolve in accordance with both traditional roles and emerging needs. Public need or demand has been the major impetus for subspecialization in psychiatric nursing, with the second impetus being new knowledge pertinent to the mental health field (Murphy, 1987).
A clear trend toward subspecialization within psychiatric and mental health nursing can be documented during the past three decades. The 1950s marked the emergence of the first subspecialty in the field, which was child psychiatric nursing. During the 1960s, a second subspecialty, psychiatric liaison nursing, was developed. Several other subspecialties began to evolve during the 1970s, including substance abuse (or addiction) nursing and gerontological mental health (or geropsychiatric) nursing. Nursing care of the chronically mentally ill gained renewed attention (Murphy, 1987).
Care of the elderly hinges on understanding and being able to affect the multiple and complex biological, psychological, social, and spiritual factors that affect their quality of life. By the time people reach advanced age, they are at a pinnacle of human complexity that requires a special sensitivity to issues related to aging. The chronicity, complexity, and multiplicity of problems in the elderly mandate that highly qualified nurses must be prepared to offer comprehensive care (Philipose, 1991).
The geropsychiatric clinical nurse specialist’s role in the promotion of mental health, prevention of mental illness, and nursing care of the mentally ill elderly population must be based on sound theoretical and research foundations (Buckwalter, 1992). Subspecialization in geropsychiatric nursing builds on the specialist preparation obtained in graduate level psychiatric/mental health nursing or gerontologic nursing education. Advanced graduate education (preparation of a subspecialty) provides students with opportunities to acquire the theory and skills necessary to function as a geropsychiatric clinical nurse specialist in a variety of settings.
An Overview of Geropsychiatric Clinical Nurse Specialist Curricula
The following curriculum information is intended to aid students and faculty in planning individual and group program options. The recommended clinical experiences reflect a belief that professional education is a lifelong responsibility and includes both formal and informal approaches to learning. Graduate education is seen as providing students with the opportunity to develop competence as clinicians at a beginning specialty level. A high degree of motivation, and an ability to develop personal learning goals and implement a self-directed program of learning, are essential to both academic and professional excellence.
The multifactorial nature of problems addressed by nurses in advanced geropsychiatric/mental health nursing is emphasized by selected theory and research bases. In addition to becoming familiar with a broad range of theoretical and research literature relevant across client groups, therapeutic modalities, and professional roles, students are expected to identify specific learning goals for developing expertise in an advanced practice role with the elderly (Abraham, 1994; Hoeffer, 1994).
Classroom knowledge is the basis for growth; supervised clinical experience is the mechanism for growth from student to geropsychiatric clinical nurse specialist. The apprentice learns professional behavior through the application of knowledge through clinical experiences. This article is primarily concerned with that application. Much of the information may be seen to represent an integration of information from a variety of sources, including the authors’ own experiences. Students developing clinical specialist skills in geropsychiatric nursing progress along a continuum of increasing knowledge and practice. A base of substantive knowledge gained in the classroom is supplemented by, and built upon, a series of supervised clinical experiences, each representing increasing skill and professionalism.
Students should have completed a 2-year program for clinical specialization in psychiatric/mental health nursing or gerontological nursing. Previous course work ideally would focus on such areas as contexts for practice; theoretical and research perspectives, which guide practice; and an introduction to specialized roles of nurses. Historical, legal, political, and ethical issues will have been explored. The importance of group, community and organizational dynamics in the practice of advanced psychiatric/mental health nursing (assessment of clients, choice of therapeutic interventions, and professional role development in advanced practice) will have been addressed prior to the third year of the curriculum, which focuses on development of a subspecialty in geropsychiatric nursing.
Supervision.
Individual supervision is an intense learning experience. Students learn about the clinical specialist role by interacting with a supervisor who is qualified to provide feedback about the approaches the student is using in the current clinical placement. Students are encouraged to identify possible preceptors who are qualified to supervise their clinical practicum in the field of geropsychiatric nursing and/or in a specialized role in geropsychiatric nursing (eg, geropsychiatric liaison nurse to long-term care facilities).
Because of the paucity of professional nurses who are geropsychiatric clinical nurse specialists, supervision from other disciplines (eg, psychology and psychiatry) may be necessary. In this case, to maintain a sense of professional identity, student group and individual supervision from the nursing faculty is a desirable adjunct to supervision by the non-nurse clinical preceptor.
Curricula Components
Assessment.
The ability of the geropsychiatric clinical nurse specialist to address clinical problems is directly related to the comprehensiveness and depth of the data obtained from clients, their families, and evaluations from other health care professionals (eg. ability to read and understand the report of a neuropsychologist).
The geropsychiatric clinical nurse specialist has an understanding of normative aging, as well as the multiple biological, behavioral, psychological, and social problems commonly associated with aging. Assessment is the starting point for treatment or intervention; therefore, strong interviewing techniques and experience with physical assessment are essential skills for the geropsychiatric clinical nurse specialist (Thompson-Heisterman, 1992).
A portion of the clinical practicum (preferably the first semester of clinical placement for the geropsychiatric subspecialty) should be as a member of a multidisciplinary geriatric assessment team, either in the acute care or community setting. During this clinical experience, the clinical nurse specialist will have exposure to comprehensive medical, psychological, social, and functional assessment of the elderly client. Participation on the geriatric assessment team provides exposure to such activities as the following:
Psychiatric history and mental status assessment;
Social history assessment (including formal and informal social support systems);
Functional abilities evaluation;
Medical evaluation;
Neurologic evaluation (eg, electroencephalography and neuroimaging); and
Neuopsychologic (psychometric) testing.
Additionally, the clinical nurse specialist will have exposure to the referral process to community service providers (such as a case management project). While participating in the multidisciplinary geriatric assessment process, the geropsychiatric clinical nurse specialist is concerned with gaining skills in geriatric psychiatric/mental health assessment.
Geriatric mental health assessment is a multifaceted process that includes a complex interplay among physical, mental, social, economic, spiritual, environmental, and treatment factors. Thus, the geriatric mental health assessment should include the following:
Physical history (to include both medications prescribed and over-the-counter medication used, as well as compliance with and tolerance of the medication regimen, allergies, chronic and acute illness, somatic concerns, and drug/alcohol history);
Mental status assessment (general appearance and behavior, flow of thought and speech, affect, mental content of speech, sensorium, cognitive status, intellectual resources, insight, and judgment);
Social history (interpersonal relationships, role function, vocational history, legal history, educational level, and both formal and informal support systems);
Activities of daily living and functional limitations; and
Coping mechanisms and resources (Buckwalter, 1990).
Long-Term Care Facilities.
Long-term care facilities are an ideal setting for the geropsychiatric clinical nurse specialist to gain clinical experience. Long-term care facilities provide exposure to clients with physical, social, and emotional impairments.
In a long-term care setting, the geropsychiatric clinical nurse specialist has the opportunity to expand his or her understanding of psychopharmacology, sharpen assessment skills, and apply psychotherapeutic techniques with the institutionalized aged and their family members. Therapeutic modalities practiced in the long-term care setting include milieu therapy and environmental modification; individual, family, and group therapy; crisis intervention; psychopharmacology; behavior management; psychoeducation; and nonverbal therapeutic modalities, such as music, movement, and art therapy.
The long-term care setting will familiarize the geropsychiatric clinical nurse specialist with the rules, regulations, and legislation that affect long-term care. She or he will become familiar with long-term care facility assessment procedures. such as Minimum Data Set and Pre-admission Screening and Annual Resident Review; financial reimbursement systems, such as Medicare and Medicaid; and the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987).
Activities of daily living and functional limitations should be assessed in the geriatric patient.
The geropsychiatric clinical nurse specialist plays a key role in providing psychiatric/mental health consultation and education, as well as acting as a role model to personnel in long-term care facilities. There is evidence in the literature that long-term care personnel are not knowledgeable about the aging process and are ill-prepared to manage the psychological and behavioral problems that occur in more than 75% of nursing home residents (Meunier, 1987; Smith, 1990).
Some studies have suggested that nursing home staff members often contribute to the development of behavioral problems in residents (Baltes, 1980, 1983). The geropsychiatric clinical nurse specialist provides education and consultation to long-term care staff, family members, administrative staff members, and boards of directors in the psychological facets of resident care, social factors in group structuring, cultural factors in staff training, spiritual issues in dignifying death, and environmental issues in facility arrangements (Smyer, 1988). He or she also educates/consults on medication, behavior and milieu management, and diagnostic-specific nursing interventions (eg, dementia, depression, delirium, and paranoia).
In long-term care facilities, the geropsychiatric clinical nurse specialist will have the opportunity to sharpen psychotherapeutic techniques with the elderly population. Studies show the prevalence of psychiatric disorders among nursing home residents to be as high as 94% (Rovner, 1986).
Psychotherapy with the elderly population requires the geropsychiatric clinical nurse specialist to individualize psychotherapeutic interventions in a flexible manner, and takes into account the need to change to another therapeutic approach because of crisis or change in health/cognitive status. Individual psychotherapeutic techniques, which benefit people of any age, can be adapted to meet the specific needs of elders in long-term care facilities.
Community Based Mental Health Settings.
In most communities there are a variety of clinical practicum sites available to the geropsychiatric clinical nurse specialist. Approximately 32% of elders live alone in the community; approximately 54% live with their spouses (Harper, 1992). Community and private practice mental health centers, mental health crisis centers, geriatric day care centers, senior citizen programs, well elderly clinics, hospice programs, and hospital based day treatment programs are all potential sites for a geropsychiatric clinical nurse specialist clinical practicum.
There may be less of a multidisciplinary focus in community-based mental health settings than in most inpatient settings. Because of this professional isolation, clinical supervision from a mental health professional with expertise in the area of gerontologic psychotherapy is essential. The clinical preceptor can help the novice geropsychiatric clinical nurse specialist address such psychotherapeutic issues as transference, countertransference, use of defense mechanisms, and termination of the therapeutic relationship.
Individual, group, family, and couples therapy are specific treatment modalities that can be practiced in the community setting. Selection of a time for therapy and the therapeutic approach are determined by the geropsychiatric clinical nurse specialist, the client, and the clinical situation. Valuable dimensions of human behavior can be overlooked if the geropsychiatric clinical nurse specialist is restricted to a single psychotherapeutic theory; however, an undisciplined, eclectic approach cannot be an excuse for failing to develop a sound rationale for systematically adhering to certain concepts and techniques (Corey, 1986).
Adaptation to the stresses of life and losses associated with aging can be accompanied by a variety of difficulties, which could be indications for individual psychotherapy (Pollock, 1987). Issues of esteem, loss of control, change in role function, grief, life review (existential issues), and coping mechanisms are examples of the broad range of psychotherapeutic issues relevant to the elderly.
Lazarus and colleagues (1991) noted the following:
[I]nsight oriented, intensive psychotherapy is indicated most frequently for the normative aging cohort and is most productive when the client is motivated; has the capacity for self-observation, insight, and mourning; is able to tolerate painful affects without excessive decompensation; and has demonstrated a capacity for productive work, intimacy, and pleasure.
The elderly are faced with issues of adaptation to loss; conflicts related to feared or actual sexual decline; loss of identity or role function; marital/family conflict; fear of dependency; failure to achieve goals in life; and coming to terms with mortality and the imminence of death (King, 1980).
As a person ages or their health deteriorates, crisis intervention techniques may be helpful. Supportive therapy is generally indicated until the client’s defenses and adaptive capacities have been strengthened. Psychotherapy in these circumstances is often an adjunct to medical, pharmacologic, and environmental support (Lazarus, 1991).
The frail elderly do not always have the capacity to tolerate intensive psychotherapy. However, they may benefit from the use of solution focused, short-term therapy models described by DeShazer (1988) and O’Hanlon and Weiner-Davis (1989). Psychotherapy specifically adapted to the frail and institutionalized elderly has been successfully used (Aronson, 1958; Sadavoy, 1983, 1989). The more frail the elderly client is, the greater the indication for solution-oriented interventions, such as behavioral therapies and environmental manipulation (Hall, 1987; Kahana, 1987).
Inpatient Psychiatric Settings.
Inpatient psychiatric treatment in an acute care setting is an important component of the comprehensive services available to elderly psychiatric clients. In this setting, the geropsychiatric clinical nurse specialist continues to develop physical and psychiatric assessment skills, work with a multidisciplinary team of specialists concerned with the health needs of the elderly, and be involved in discharge planning with collaboration and cooperation with community agencies.
The inpatient setting is used when the geropsychiatric client is an imminent danger to self or others, is in need of intensive evaluation and/or treatment that cannot be provided in an outpatient setting, or when there is failure of the caregiving system (lack of family/community resources or respite care beds in less intensive treatment settings). Opportunities to practice several treatment modalities may be found in the inpatient, acute care setting, and include such areas as milieu, individual, behavior, group, family, physical, occupational and recreational therapy, and psychoeducation (Tourigny-Rivard, 1991).
Available practicum sites vary from community to community. The student may have sites available that primarily serve the elderly population (eg, nursing homes, senior citizen centers, nutrition sites, congregate housing, well elderly clinics) or sites that serve the elderly only incidentally (eg, community mental health centers, hospitals, crisis mental health centers).
In order to fully assess the effect of illness, disability, psychological, and family interactions, as well as problems with daily living, the geropsychiatric clinical nurse specialist will benefit from becoming familiar with the elderly client’s home environment (Harper, 1992). An ideal clinical practicum would include a mix of institutional settings, noninstitutional (community) settings, and in-home (outreach) experiences.
Special Populations.
There are a number of special populations within the geropsychiatric community. There are diagnostic specific groups, such as elders with a diagnosis of dementia or substance abuse, and groups segregated by geographic dimensions, such as homeless and rural mentally ill elders. It has been documented that both rural and homeless elders are underserved populations and in need of outreach mental health interventions (Buckwalter, 1991; Budreau, 1992).
Students with special areas of interest can direct their clinical practicum toward the development of extra knowledge in that specialty area. For example, if a student is particularly interested in suicide in the elderly population, then clinical practicum sites can be tailored to meet the student’s educational and experiential needs.
In the inpatient hospital setting, the student may be able to follow the hospital course of a suicidal elderly client. In the well elder clinic, the student could do mental health screening, assessing for people who are suffering from signs of depression and who are at risk for potential suicide. In the elder day care center, through individual therapy sessions, the student could apply principles of cognitive behavioral therapy, logotherapy, or grief therapy with depressed clients.
Conclusion
The fastest growing segment of our population today is composed of the elderly, yet they remain vastly under-served when considering their mental health needs. There are a number of barriers that prevent the elderly from receiving needed mental health care, including the following:
Inaccessibility of services because of transportation or mobility problems;
Lack of ability to pay for services;
Devaluation of the potential benefits of psychotherapy by elders and clinicians;
Stigma associated with psychiatric help in the older generation;
Lack of professionals educated to understand the special mental health needs of the elderly; and
Age bias on the part of mental health professionals, who view the elderly as an unappealing and incurable group of people with whom to work (Buckwalter, 1985).
Geropsychiatric nursing is emerging as a much needed subspecialty that blends the knowledge and skills of psychiatric, community, and gerontologic nursing to help overcome some of the barriers listed above. The ability to understand and affect the multiple biopsychosocial interactions that contribute to psychosocial maladjustment in the elderly requires a high level of skill and knowledge.
The clinical practicum component of curricula is where the nurse specialist sharpens skills and applies knowledge learned in the classroom. Through theoretical development, clinical refinement, and research validation, the geropsychiatric clinical nurse specialist can be in an advantageous position to meet the challenges of our aging society.
Essential Clinical Experience KEY POINTS.
Essential Clinical Experience for Subspecialty Development in Geropsychiatric Nursing. Garand, L.J., Buckwalter, K.C. Journal of Psychosocial Nursing and Mental Health Services 1994; 32(4):27–32.
Subspecialization in geropsychiatric nursing builds on the specialist preparation obtained in graduate level psychiatric/mental health or gerontologic nursing education
Development of a subspecialty requires a base of substantive knowledge gained in the classroom, supplemented by a series of supervised clinical experiences.
Clinical practicum experiences with specific role options for the geropsychiatric clinical nurse specialist and experiences with special populations are essential to the further development of geropsychiatric nursing as a subspecialty.
Advanced graduate education provides students with opportunities to acquire the theory and skills necessary to function as a geropsychiatric clinical nurse specialist in a variety of settings.
The more frail the elderly client is, the greater the indication for solution-oriented interventions, such as behavioral therapies and environmental manipulation.
In the elder day care center, through individual therapy sessions, the student could apply principles of cognitive behavioral therapy, logotherapy, or grief therapy with depressed clients.
Clinical experiences relevant to the educational development of a geropsychiatric clinical nurse specialist are necessary to the successful development of geropsychiatric chiatric nursing as subspecialty. This article delineates clinical practicum options that aid faculty and students in planning the prerequisite individual practicum experiences.
Role Development.
Three social forces have been attributed to the development of specialization in any field:
New knowledge pertinent to the field;
Technological advances; and
Response to public need or demand (Hoeffer, 1984; Murphy, 1987; Smoyak, 1976).
The concept of the psychiatric clinical nurse specialist was formalized in
Acknowledgments
This article was funded by the National Institute cf Mental Health/Mental Disorders of Aging Research.
Contributor Information
Linda J. Garand, Geropsychiatric Clinical Nurse Specialist and a doctoral Student, University of Iowa, College of Nursing. Iowa City..
Kathleen C. Buckwalter, Professor and Associate Director, University of Iowa, College of Nursing. Iowa City..
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