1. Elliott, Dolores MSN, RN, APRN/PMH, PMHCNS-BC

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The traditional healthcare landscape is changing and many patients experience mental health crises not only on psychiatric units or in the ED, but also on medical-surgical or specialty units. At the National Institutes of Health Clinical Center (NIHCC), the board-certified advanced practice psychiatric and mental health clinical nurse specialist (APRN-PMH) is meeting this evolving patient need. The role is population-based, supporting the patient, family, and nursing staff during the research process by providing evidence-based treatment approaches to optimize the patient's level of functioning. Relationship-centered care is the central paradigm of the psychiatric nursing specialty. The APRN- PMH expands these paradigms by incorporating neurophysiologic, evidence-based psychotherapy approaches; psychopharmacology; and a theoretical framework to formulate individualized patient treatment plans.1

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The APRN-PMH role

The APRN-PMH is an advance practice nurse who's prepared at the graduate level in research, systems, and direct patient care to establish a mental health diagnosis and provide psychiatric evaluations and treatment. This includes psychotherapy; cognitive behavioral therapy; psychobiologic interventions; and individual, family, and group therapy, as well as primary, secondary, and tertiary levels of prevention across the lifespan. Prescriptive authority and reimbursement for clinical services are state dependent.1 Each state independently determines the APRN-PMH legal scope of practice, role recognition, and the requirements for certification accepted for entry-level competence assessment. The legal right to use any given title is based on the individual state's statutory authorization and there may be variation by state.2


Research literature has found that the conveyance of respect, active listening, consistency, follow through, acceptance of the patient's problems and faults, and partnership are critical in the development of a quality therapeutic relationship.1 The APRN-PMH must know how to accurately assess the problem, engage, and intervene to meet the patient's needs while providing support and maintenance of a safe environment for both the patient and nursing staff. The elastic scope of the APRN-PMH role is essential in providing comprehensive, individualized, and collaborative practice for patient safety and achieving positive outcomes. The APRN-PMH supports the research patient's protocol journey by offering specialized knowledge, skills, expertise, and abilities obtained through licensure, accreditation, American Nurses Credentialing Center specialty certification, education, and competencies.


The APRN-PMH at the NIHCC collaborates with nursing staff throughout the hospital to meet patients' needs and promote mental health in complex situations. This unique role offers relationship-based support to patients who experience depression, loss, anxiety, isolation, life-threatening illness, chronic pain, delirium, hopelessness, helplessness, loneliness, history of mental illness/trauma, suicidal thoughts, or other life stressors resulting in dysregulation. The APRN-PMH understands how anxiety creates a feeling of helplessness and disempowerment, preventing healing.1


The therapeutic partnership and caring contact enable the expression of worries, emotions, distress, and fear in an empathetic and supportive environment to ensure patients' comfort during research. Often, patients perceive enrollment in NIH protocols as their last hope for recovery, adding to heightened anxiety levels and the need for advanced practice nursing support. This partnership facilitates informed decision making, positive lifestyle changes, and appropriate self-care during illness transition.


The APRN-PMH scope of practice assumes the responsibility and accountability for clinical functions using a range of therapy models, such as an interpersonal relationship to produce change or supportive care to maintain patient function during protocol requirements. The APRN-PMH receives informal consultation requests from all nonbehavioral inpatient, day hospital, and outpatient areas. These consults are requested from clinical research nurses, managers, other clinical nurse specialists, principal investigators, the pain and palliative care department, and other interdisciplinary team members to provide approachable and comforting nursing interventions that will create a connection with patients.


Prompt response builds trust. Consults include patients who at the end of life or experiencing addiction withdrawal/complications, delirium, agitation, depression, suicidal thoughts, high fall risk, hallucinations, challenges, and/or anxiety requiring multifaceted interactions. The APRN-PMH assesses patients without labelling them as "difficult," "agitated," or "hostile." These labels don't consider the contributing factors of the behavior. Due to the nature of complex diseases, NIHCC research patients have longer lengths of stay, requiring intensive support and pharmacology knowledge. The use of acceptance, understanding, honesty, and empathy supports the patient during crisis, as well as the clinical research nurses who carry out critical protocol requirements.1


Empowering patients

True presence requires active listening to understand the meaning of a situation in the moment for the patient, mitigating potentially high-risk situations and maintaining patient safety.1 Being available, genuine, and respectful helps the patient who's struggling with his or her diagnosis to set daily goals.3 See Case Study and consider the following examples.


A terminally ill patient's wish was to celebrate her 9-year-old daughter's future major life events. She purchased jewelry to celebrate her daughter's school graduations, engagement, marriage, and birth of her children. She proudly showed the nurses these purchases, which made her smile and gave her closure before her death. She was able to discuss her death with her family as a peaceful journey after a 5-year battle with cancer. This support boosts the clinical research nurses' engagement with patients, empowering their role and increasing nursing satisfaction and resiliency.


In an outpatient area, a 23-year-old patient with cancer was scheduled to receive five rounds of chemotherapy. He was extremely anxious and hopeless; the clinical research nurse had concerns about his distress and worried that he may not be able to complete protocol requirements. The APRN-PMH assessed the patient for depression, anxiety, and suicidal ideation, and ensured that appropriate evaluation, evidence-based treatment, and follow-up care were provided. The patient was able to receive chemotherapy and complete protocol requirements. His nurse described him as "a new person who's no longer crying and shaking" during chemotherapy. The patient described feeling more hopeful, calmer, and able to cope with the treatments and the uncertainty of his future.


Evidence suggests that evaluation of the therapeutic alliance is measured by examining baseline patient behaviors and symptoms, and the patient's progress at measurable data points, such as he or she is able to verbalize feelings and use coping strategies instead of becoming agitated with staff.1 There's a here-and-now positive difference in interpersonal interactions with nursing staff during periods of crisis, preventing escalation and potential violence. Investing in the clinical nurse specialist role promotes not only excellence in practice, but also improves recruitment and retention of nurses at the bedside by providing support and mentorship while meeting patient needs.


The APRN-PMH offers a good return on investment in acute care settings by reducing length of stay and cost of care for hospitalized patients.4 APRN-PMHs can bill for services using psychiatry specialty codes.1 They can safely augment the physician supply, providing high-quality and effective patient care.4 The role encourages and supports greater patient involvement in care and self-management for positive behavioral health outcomes throughout the hospital. Research demonstrates the cost-effectiveness and efficacy of behavioral interventions for hospitalized patients.1 The expert consultation to clinical nurses empowers them to recognize and de-escalate potential difficult conflict situations.


Expertise where it's needed

The development of a therapeutic relationship requires complex skills, including demonstrating respect, clear boundaries, and self-awareness.3 The APRN-PMH provides clinical expertise and applies many skills in the establishment of the nurse-patient relationship, such as understanding the patient's nonverbal communication and ascribing meanings to behavior. A key element of the APRN-PMH role is creating environments through mentorship and system changes that empower nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical decision making, prevent adverse events, and respond to diversity.


The APRN-PMH plays a significant role in today's ever-changing and complex healthcare system by using evidence-based interventions to decrease length of stay/cost; manage delirium; identify and manage cognitive changes, particularly in the aging population; detect suicidal ideation; deescalate agitation, especially in the ED and on the ICU; and support complex protocol paradigms to mitigate risks and promote patient safety. The APRN-PMH's expertise and competencies can also shepherd an organization's desire to achieve or maintain Magnet(R) recognition. The APRN-PMH is essential in providing comprehensive, individualized, and collaborative practice for patient and staff safety; promoting positive patient outcomes; supporting management; and upholding the institutional mission while furthering the advancement of nursing practice.


Case study

Mr. T is 41-year-old divorced, disabled male patient diagnosed with Von Hippel-Lindau disease at age 10. He also has hypertension, diabetes, and alcohol use disorder. He has had four nephrectomies and five craniotomies over the past 10 years, and he's scheduled for a pancreatectomy. He's had numerous admissions since 1998 and a long history of alcohol abuse with limited insight; he denies the need for alcohol rehabilitation and has no interest in attending Alcoholics Anonymous meetings. He denies past treatment for alcohol withdrawal and states that he drinks due to boredom and doesn't remember ever having withdrawal symptoms, seizures, or blackouts in the past.


He arrives at the NIHCC intoxicated, concealing a bottle of gin in his backpack and with slurred speech. The nursing staff and psychiatrist request a consult with the APRN-PMH regarding the potential for alcohol withdrawal. The use of the Clinical Institute Withdrawal Assessment for Alcohol Scale to measure the patient's withdrawal is recommended. His score is 20, necessitating the use of lorazepam for withdrawal symptoms based on a symptom-triggered treatment approach, which decreases the use of benzodiazepines and cost, promotes patient safety, decreases hospital length of stay, and improves patient outcomes. Mr. T had a positive detoxification treatment and surgical outcome.




1. Wheeler K. Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-To Guide For Evidence-Based Practice. 2nd ed. New York, NY: Springer Publishing; 2014. [Context Link]


2. National Council of State Boards of Nursing. NCSBN's APRN campaign for consensus: state progress toward uniformity. [Context Link]


3. Dziopa F, Ahem K. What makes a quality therapeutic relationship in psychiatric/mental health nursing: a review of the research literature. [Context Link]


4. Newhouse RP, Stanik-Hutt J, White KM, et al. Advanced practice nurse outcomes 1990-2008: a systematic review. Nurs Econ. 2011;29(5):230-250. [Context Link]