In response to calls to improve health outcomes and reduce health burdens in patients with chronic disease and behavioral health diagnoses, our fully online doctor of nursing practice (DNP) advanced practice registered nurse (APRN) program developed an innovative curriculum strategy implemented in 2012. The program integrates primary care (family, pediatric, and adult-geriatric) APRN track students and psychiatric mental health nurse practitioner (PMHNP) students into one curriculum, addressing content across all tracks. Typically, APRN programs with multitrack focus areas have limited curriculum integration beyond foundational APRN courses, such as advanced pathophysiology, pharmacology, and advanced physical health assessment. The integrated approach is designed to address credit hour equity and faculty workload while allowing for increased numbers of students. The integrated courses are titled Advanced Care Management 1, 2, and 3.
The program sought and received approval for an additional PMHNP track in 2016. Faculty desired an innovative model in which PMHNP competencies, coupled with primary care, were integrated into an established curriculum without leading to increased faculty demand and siloed learning. This programmatic evaluation article describes the inclusion of the PMHNP track curriculum into the established online primary care APRN curriculum and the effects on faculty workload, board certification pass rates across tracks, and student evaluations.
BACKGROUND
In integrating behavioral health into primary care for PMHNP students, faculty utilized the American Association of Colleges of Nursing (2006) Essentials for Doctoral Education and National Organization of Nurse Practitioner Faculties core competencies (Thomas et al., 2017). These competencies ensure that core knowledge and scientific and evidence-based practice principles by specialty foci are taught for the treatment of diverse and vulnerable populations, according to specialty. (They do not dictate how content is delivered.)
The Agency for Healthcare Research and Quality published a guide for the integration of behavioral health and primary care in which it is suggested that the integration of foci leads to improved health care and lowered health costs (Cohen et al., 2015). Peterson et al. (2019) descrbied a model involving PMHNP students and pharmacy students that resulted in sustained student and faculty satisfaction, high course outcomes, and positive clinical site evaluations. Another model, by Weber et al. (2015), blends content specific to behavioral health in a stand-alone course for all APRN students.
The definition of health by the National Institutes of Mental Health (2020) has both physical and mental health components and is bidirectional. Patients with behavioral health problems have higher rates of adverse health behaviors that lead to increased rates of chronic disease and decreased life expectancy. They often fail to receive preventative services and have poor long-term health outcomes. Heart disease, cancer, respiratory conditions, and metabolic disorders are among the most common underlying causes of mortality in patients with behavioral health diagnoses (Gerrity, 2016). An additional concern is that patients with comorbid substance use disorders are challenged to engage in both behavioral health and primary care. APRNs are increasingly required to manage patients with several comorbid diseases and behavioral health conditions, supporting the need for all students to possess broader knowledge of primary care and behavioral health disorders while still meeting focus competencies.
MODEL IMPLEMENTATION
Our program utilizes a constructivist framework that builds student knowledge and skills while encouraging collaboration and critical thinking. Faculty mapped and analyzed the APRN curriculum scaffolding primary care and behavioral health content throughout three advanced care management (ACM) courses that follow advanced pathophysiology, advanced psychopharmacology, and advanced health assessment. A five-step problem-based learning (PBL) model developed and utilized in the ACM courses mirrors assessment, diagnosis, and the development of treatment plans for clients in health care settings. PBL cases unfold over two weeks with prescribed steps that facilitate the diagnostic reasoning process. (These steps are outlined in Supplementary Content Table 1, http://links.lww.com/NEP/A347.) Each ACM course has six PBL cases that scaffold in complexity over three semesters for a total of 18 cases.
Primary and secondary diagnoses were developed for each case, ensuring that the top diagnoses, medications, therapeutic modalitites, and preventative measures are discussed. Faculty created two casebooks, each beginning with the same chief complaint but ultimately concluding in different diagnoses. This method highlights the complexity of the diagnostic reasoning providers must engage in when evaluating patients. The casebooks are written to reflect the ability of students to rule in and rule out differential diagnoses and develop comprehensive assessments and treatment plans. FNP and PMHNP students work in tandem, covering the same "patient" but using casebooks for their specific focus, ensuring that both tracks cover the life span. PMHNP casebooks work through 32 psychiatric diagnoses (including substance abuse and eating disorders) and a multitude of common comorbid conditions. (See Supplementary Content Table 2, http://links.lww.com/NEP/A348, for an example of primary and secondary diagnoses covered by focus areas and Figure 1, http://links.lww.com/NEP/A349, which reflects overlap conditions in a patient.)
RESULTS AND STUDENT COMMENTS
Student evaluations of the integrated course were compared to the 2016 cohort. Average aggregate evaluation scores were 4.59/5 for ACM 1, 4.75/5 for ACM 2, and 4.65/5 for ACM 3. Student comments included "I liked how interactive it was and educational it was," "I love this class. I feel like we actually learn something about each of the diagnoses for each PBL." Recommendations from the first cohort after integration included the following: "Suggest facilitating a discussion where students were able to converse with one another on a treatment plan, with PMHNP students focusing on mental issues and AGNP/FNP or PNP students focusing on medical issues" and "The pathophysiology of psychiatric disorders is not as straightforward as medical issues such as pancreatitis or hypertension." Average grades for ACM 1, ACM 2, and ACM 3 were 3.8, 3.9, and 3.8, respectiveily, for the cohort at large (n = 61) and 3.8, 4.0, and 4.0, respectively, for PMHNP (n = 5). Feedback was carefully reviewed and led to revision of Step 5. Faculty created discussion questions that drove students to alternate foci casebooks and engage in targeted discussion to enhance learning. A review of pathophysiology for PMHNP diagnoses and its relationship to presenting complaints was provided.
Since integrating the curriculum, Board certification pass rates for FNPs have sustained above the national average at 93 to 95 percent; for PMHNPs, the rate has consistently been 100 percent. Course evaluations have been sustained at 4.65/5. Students' comments reflected sentiments such as the following: "PBLs allow us to communicate with our peers in a safe space that prepares us for real life collaboration in the clinical setting. The added bonus of having a clinical expert (faculty) monitor our conversations enhances our discussion" and "Deepens understanding of underlying pathology of mental disorders[horizontal ellipsis]. Provides holistic education by allowing access to other specialty discussion boards." Our program enrolled a cohort of 26 PMHNP students that started ACM 1 in the summer of 2021; 8 were post-master's PMHNP students who already held licensure in a primary care track (FNP, AGNP, PNP) certification. We integrated those students within groups of five that included novice BSN to DNP APRN working with experienced PMHNP faculty; they are currently completing their final clinical course.
Development of an integrated curriculum model that addresses the focus competencies in an integrated setting is an effective model for maximizing faculty resources. The first cohort of the combined primary care and PMHNP DNP students graduated in May 2019 and reflected ease of integrated cohorts, enhanced student learning, and a feasible faculty workload model. Addition of one PMHNP faculty to each ACM course working in tandem with the primary care faculty was successful and maintained the ratio of one faculty per 5 to 15 students.
CONCLUSION
Integration of PMHNP track foci into an established, sustainable, fully online APRN curriculum is an effective means to ensure integration of APRN essentials and competencies for both primary care and PMHNP APRN students. Course evaluations and outcomes reflect student success and positive feedback on the importance and relevance of this model. This model of integrated curriculum design provides a framework in which to educate multiple APRN foci while meeting competencies for credentialing and is one that can be replicated by other programs.
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