Published on March 10, 2014
` The objective of this review is to assess the outcomes of incorporating primary care services into psychiatric care settings, with regards to comparing care provided by psychiatric nurse practitioners vs. physician and psychiatrist teams in establishing the effectiveness of care provided by assessing patient outcomes. Data sources for this study include PubMed, PsychINFO, and the Cochrane. Study selection entailed studies assessing services of medical care in a psychiatry clinic or in psychiatry ward. Trials entailing services of psychiatry within clinics that offer primary care were not included. Data illustrating the patient population, intervention, deliberate outcomes, and discussion of points were collected. Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists ABSTRACT 1 Copyright © Lolitha I. Shepherd 2013
` It was established that various models of incorporated care exist and clients within these integrated sets obtained more preventive health interventions and revealed enhanced scores on the outcomes of health. The data collected revealed that incorporating PMHNP’s (psychiatric and mental health nurse practitioners) into the primary care and psychiatric care settings improves maintenance of health, coordination of care, and satisfaction with medical care overall both psychiatric and non-psychiatric. Upcoming research studies need to further address expense, primary care physicians’ training to provide care to psychiatric health patients in primary care settings and whether this incorporated model is more successful in these settings. It is argued that the care provided by the psychiatric nurse practitioner, physician and psychiatrist in patients with chronic illness is comparable. Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists ABSTRACT (CONTI) 2 Copyright © Lolitha I. Shepherd 2013
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists INTRODUCTION 3 The role of nurse practitioners is expanding along with their scope of practice. Nurse practitioners are advanced practice nurse’s that along with physician assistants are more often being referred to as mid-level providers (Casher, et al, 2012). This study provides a comparison of patient outcomes with regards to care from a psychiatric nurse practitioner or a physician and psychiatrist team in the delivery of primary health care. Copyright © Lolitha I. Shepherd 2013
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists TARGET POPULATION 4 Copyright © Lolitha I. Shepherd 2013 Veterans with chronic mental health diagnoses as well as other co- morbidities.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CLINICAL PROBLEM 5 Copyright © Lolitha I. Shepherd 2013 Patients suffering from the negative effects of adverse medication interactions due to being managed by multiple providers. A report from the Clinical Antipsychotic Trials of Intervention Effectiveness cited that non-treatment rates for hypertension, dyslipidemia, and diabetes were 62.4%, 88.0%, and 30.2%, respectively, implying that patients cared for principally within the setting of mental health care are not getting comprehensive management. The intervention is having a psychiatric nurse practitioner on staff to offer primary care management as well as mental health management to patients. The Incorporating primary care into psychiatric settings can enhance the quality, satisfaction, and clinical results in the care of patients (Laustsen, 2013).
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CLINICAL PROBLEM (CONTI) 6 Copyright © Lolitha I. Shepherd 2013 The proposed outcome is that under the care of the PMHNP (psychiatric and mental health nurse practitioner) the veteran will receive more consistent care with less medication interactions as it will not be ordered by multiple health providers and reviewed more closely leading to better management of mental health disorders and co-morbidities, as well as better compliance with treatment due to more thorough explanations and a general better rapport with nurses than physicians which will also decrease the cost of healthcare.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CRITICAL APPRISAL OF THE LITERATURE 7 Copyright © Lolitha I. Shepherd 2013 The literature exclusive to psychiatric/mental health appears to be concerned with the alleged nature and scope of practice, instead of the patient outcomes based on the care itself. Casher, et al, (2012) argues that successful integration of psychiatric nurse practitioners requires a clear understanding of their roles, the outcomes, and likely benefits of the role of nurse practitioners, it is imperative to evaluate literature relating to the wider general field of health care. There is substantial research support to imply that the satisfaction that patients get with the management provided by nurse practitioners is to some degree equal to that offered by physicians.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CRITICAL APPRISAL OF THE LITERATURE (CONTI) 8 Copyright © Lolitha I. Shepherd 2013 In a research project done by Grispini (2011), patients showed a greater degree of satisfaction with psychiatric nurse practitioners in spite of the fact that the outcomes between them and physicians had little variation. On average 25% of all patients seen by primary care physicians suffer from a mental health problem as well. The result is physicians handling a great percentage of moderate to severe psychic problems and not being totally comfortable doing so. Many physicians are not trained to specifically treat mental health disorders they are not totally comfortable doing so and do not provide in-depth medical advice or treatment plans in those areas (Grispini, 2011). The findings of a randomized multi-centre, controlled trail carried out in the UK, established that the degree of client satisfaction was equal between doctors and nurse practitioners, although, nurse practitioners appeared to order further tests and planned more follow-up appointments compared to general practitioners.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CRITICAL APPRISAL OF THE LITERATURE (CONTI) 9 Copyright © Lolitha I. Shepherd 2013 Patient satisfaction surveys (Casher, et al, 2012) suggest favourable patient satisfaction with the services that nurse practitioners provided, in the framework of equal outcomes of health, referrals, prescriptions, and return visits. Some patients are not comfortable being treated by someone without the title of “doctor” Casher, et al, (2012). Marshall (2009) discovered that the degree of satisfaction with the care offered by nurse practitioners was comparable to that provided by doctors. The clients particularly cited the fact that nurse practitioners were more apt to offer detailed advice and information concerning health, emergency management resources, and follow-up management.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists CRITICAL APPRISAL OF THE LITERATURE (CONTI) 10 Copyright © Lolitha I. Shepherd 2013 “The clients reported being less disturbed concerning their status of health when seen by a nurse practitioner (Marshall, 2009). According to Casher, et al, (2012) individuals experiencing chronic mental health issues are prone to have drastically poorer health, even after aggressive management. The authors argue that even though these patients might have a propensity to develop co-morbidities, individuals experiencing chronic mental illness often decline to seek medical treatment O’Neill, et al, (2008).
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 11 Copyright © Lolitha I. Shepherd 2013 CRITICAL APPRISAL OF THE LITERATURE (CONTI) There was an integration of services of primary care psychiatric care at The Veteran’s Affairs Hospital in Connecticut (Cerimele & Strain, 2010). One hundred and twenty outpatient veterans were grouped randomly into an integrated team of care (medical care in clinic of psychiatry) or into two daily care clinics (primary care clinic and psychiatric clinic). The integrated clinic was managed by the psychiatric services, which encompassed the psychiatric staff including a psychiatrist in addition to a part-time family practice physician, a nurse practitioner, and a part-time administrative assistant, as well as one case manager. The daily care group received psychiatric management at a general clinic of psychiatry and routine medical care in the primary care clinic.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 12 Copyright © Lolitha I. Shepherd 2013 CRITICAL APPRISAL OF THE LITERATURE (CONTI) The patients in the integrated care group revealed higher conformity with preventive services denoted by the Preventive Services Task Force in the US Cerimele & Strain, 2010). Schizophrenic patients in particular may be a patient population that would gain from primary care and incorporated mental health management since these patients usually use the sector of mental health care as the major basis of health care. Presently, a number of groups have incorporated primary care into settings of psychiatric care and investigated processes as well as outcomes via randomized controlled studies and descriptive studies (Frellick, 2011).
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 13 Copyright © Lolitha I. Shepherd 2013 IMPLEMANTING THE EVIDENCE The target population of veterans have expressed their concern with the lack of contact with their physician or poor communication with the IDT, as well as a greater trust and rapport with nurse practitioners than other providers. Citing that having to constantly explain their concerns over and over and being referred from one doctor to another makes them feel that they are not being treated appropriately is a deterrent from seeking treatment. The negative effects caused by some of the prescribed medications on their current health status is also of great concern. Psychiatric nurse practitioners will be used in an inpatient mental health setting for several months and the outcomes will based on decreased adverse medication effects, increased patient satisfaction.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 14 Copyright © Lolitha I. Shepherd 2013 IMPLEMANTING THE EVIDENCE (CONTI) The psychiatric nurse practitioner will work onsite and evaluate the patients mental and physical health needs Develop a plan along with the patient to improve compliance and overall health. Communicating with the physician and psychiatrist will be essential since the care provided by nurse practitioners is to be overseen by a physician as there are still some medications that cannot be ordered by nurse practitioners.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 15 Copyright © Lolitha I. Shepherd 2013 EVALUATION OF PLAN To evaluate if using a psychiatric nurse practitioner as the primary provider for this population a review of the current diagnosis, nursing notes, and medication list should be done to assess for interactions and contraindications, patient concerns and problems. Patients should be interviewed or surveyed for their assessment of the care that they are receiving before and after the implementation of this plan. Other indicators would be checking the number of missed appointments, frequency of encounters with their physician, medication compliance, and lab results as measures of improvement.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 16 Copyright © Lolitha I. Shepherd 2013 CONCLUSION There are many advantages to the role of psychiatric nurse practitioner. According to Laustsen (2013), the predicament in the present system of health care results from limited access, high costs, and concerns regarding quality. The use of psychiatric nurse practitioners will help to elevate these problems The psychiatric nurse practitioner provides health promotion and prevention services for medical issues, standard screening of physical and mental health (Frellick, 2011). Transformations in the delivery of health care now puts advanced practice nurses, like psychiatric nurse practitioners, in a position to offer a wider range of services (Suter, et al, 2009). Patient satisfaction surveys are considered an essential and valid tool of efficiency in delivery of health care (Cerimele & Strain, 2010). Positive contentment with medical care is further perceived as a factor of patient conformity and successive status of health outcome.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 17 Copyright © Lolitha I. Shepherd 2013 CONCLUSION (CONTI) The hypothesis that predicts similar health outcomes was powerfully supported within the various research studies. The outcomes for patients of nurse practitioners and physicians in primary care delivery do not vary significantly. Psychiatric nurse practitioners can possibly enhance care of veterans with chronic mental illness due to their competence as mental health professionals as well as understanding of the body and medicine compared to physicians who have a great deal of knowledge about medicine and the physical, but not always so much expertise in the field of mental health.
Psychiatric Nurse Practitioner vs. Physicians and Psychiatrists 18 Copyright © Lolitha I. Shepherd 2013 DISCUSSION QUESTIONS Would you as a patient be as comfortable with the care provided by a nurse practitioner? Why or why not? Over the years there has been much discussion regarding the elimination of the role of the LPN (licensed practical nurse). As times moves on and the minimal education requirements for RN's that employer's demand continues to grow along with the role of the RN and APN do you believe the elimination of the LPN is on the horizon or are they an essential part of the healthcare team?
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