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Articulating the value of psychiatric community health nurse interventions: a secondary analysis.

This paper focuses on descriptive evidence of the nature and value of therapeutic nursing interventions (TNIs) and articulates some of the ethical dilemmas encountered by psychiatric community health nurses (PCHNs) when third-party insurance providers undervalue the professional skills and qualities required to provide these services. The PCHNs involved in this study were community health nurses with additional psychiatric nursing experience beyond the initial licensure level for a registered nurse (RN), but who did not have graduate degree preparation. TNIs are predominantly aimed at improving the psychological competency of the client and are not recognized as distinctly billable interventions by third-party payers in current United States insurance systems.

The author/researcher describes the ethical conflict experienced by these nurses when they recognized the fact that they possessed the skills and motivation to successfully help their clients but were faced with the impossibility of procuring payment for such services. Furthermore, the study findings illustrate the positive influence of specific, successful therapeutic nursing interventions provided for persons experiencing chronic and persistent mental illness as well as the impact of these TNIs on patient self-esteem, socialization, and capacity for autonomy.

The author previously reported on the findings of an original ethnographic study of psychiatric community health nursing practice including the design, methods, broad ethical issues encountered, and importance of the therapeutic relationship between the PCHN and the patient. Medically based nursing interventions (such as assessing wound healing) were funded with greater frequency than psychologically based interventions (such as assessing the degree of depression), a situation that revealed the issue of non-parity and contributed to the nurses' experience of moral distress (Sturm, 2004).

Nine broad thematic research categories were identified. The researcher's original field notes contained rich descriptions of nurse behaviors, experiences, and interactions. The two broad thematic categories coded as Nursing Interventions and Issues/Conflicts were chosen for this secondary analysis because they provided references to all areas in the original field notes that contained evidence of PCHN interventions as well as many types of issues and ethical conflicts that PCHNs experienced in practice.

The ethnographic study (Sturm, 2004) contained information and observations concerning many facets of daily agency life, nursing practice, nurse-patient interactions, leadership behaviors, nurse-supervisor interactions, and multidisciplinary interactions, some of which contained the potential for additional analyses. Polit and Beck (2008) explained that qualitative researchers commonly collect volumes of data that require further analysis beyond the original study and that a secondary analysis can allow the researcher to approach a higher level of analysis. The author's approach to this secondary analysis did not initially seek to answer a specific question. Instead, in keeping with the tradition of qualitative inquiry, the author sought to understand frequently occurring themes and issues within the context of their occurrence. These two categories of interest were chosen because of the richness of this data and the relevancy of this data to nursing issues and practice.

This secondary analysis found evidence of specific aspects of TNIs utilized by PCHNs and descriptions of ways in which TNIs influence particular patient outcomes. This study also discusses why TNIs are considered non-skilled and non-reimbursable PCHN skills and how this contributes to the nurse's experience of moral uncertainty and distress. Re-reading and analyzing the original data (field notes) referenced and cross-referenced under the broad thematic headings of Nursing Interventions and Issues/Conflicts resulted in the identification of nine new classification categories of TNIs.

The problem

There is an absence of current, in-depth, descriptive evidence explicating the nature and value of TNIs in the context of a PCHN home practice setting. By articulating the nature and value of TNIs identified in this analysis, an awareness for the potential worth of community-based psychiatric nurses and teams that can provide comprehensive holistic nursing care may be developed and given more serious consideration by the healthcare community. The final discussion portion of this paper posits reasons that and contexts in which TNIs provided by PCHNs should be considered reimbursable skills by third-party payers.

Background

Therapeutic nursing interventions

Therapeutic communication skills form an integral part of the nurse-patient relationship, and the importance of the one-to-one nurse patient relationship has been cited in the nursing literature for more than 50 years (Frisch & Frisch, 2006; Lego, 1999; Welch, 2005). PCHNs and administrative study participants explained that therapeutic communication skills (an integral part of TNIs) are currently identified by insurance providers and nurses as non-skilled, which is the terminology utilized to describe interventions that are non-reimbursable by third-party payers. This classification does not mean that nurses who use them can do so effectively without skill, but it clarifies that managed care insurance providers do not recognize the provision of such interventions as distinctly reimbursable. Non-HMO Medicare pays for very limited psychiatric nursing assessment under specific provider criteria, and Medicaid pays for some chronic care, which may include these interventions, but coverage for chronic psychiatric care involves particularly strict restrictions. The interpersonal therapeutic interchange of the PCHN with a patient is often viewed as a less important and less tangible aspect of the nurse's visit, when, in fact, it may actually hold the greatest value for the patient's ongoing welfare. Many nurses made comments similar to one nurse's statement, "No one pays for a nurse to just talk to the patients. It's hard to show how important this is."

Simpson (2005) describes how the value of the day-to-day work of psychiatric nurses with their patients was diminished when it was restricted to the requirements of the nurses' coordinator/administrator role, a function that is given higher priority in today's healthcare systems. The nurses experienced this valuation as a conflict. Additionally, Rhein and Callahan (1999) emphasize the value of the role PCHNs play in advocating for the mentally ill living in the community. A PCHN engaged in a consistent nurse-patient relationship may be the very person who sees the early signs of patient decompensation, suicide risk, or the many subtle forms of functional loss.

The ethical dilemma

The ethical dilemma experienced by the nurses in this ethnographic study was palpable. One could see it in their expressions and hear it in their voices when they spoke of the unmet needs of their patients with chronic mental illness. The PCHNs consistently spoke about feelings of frustration and disappointment, and they exhibited resignation to the ongoing struggle required to gain permission from third-party payers for even one extra visit. The experience of an ethical dilemma in healthcare is often described in the literature as moral distress.

"Moral distress occurs when one knows the right thing to do, but institutional or other constraints make it difficult to pursue the desired course of action" (Raines, 2000, p. 30). Although this observer (as have others) frequently witnessed nurses engaged in caring acts and providing unconditional regard for their patients, those nurses did experience moral distress when they encountered a conflict between seemingly irresolvable issues in practice (Austin, Bergum, & Goldberg, 2003; Roberts, 2004; Sturm, 2004). When a nurse felt there were no further options, she often decided to move on to the next patient, conveying the sense that she had done what she could, even though it was not enough. The visible expression of what appeared to be a sense of loss and a resignation to conditions apparently outside of one's control was apparent. For example, leaving a patient's home after one particular visit, a nurse explained, "I stayed longer than I had time for; he has no family, and I only have permission for one more visit. He didn't even have the right medications in the house and he's just sleeping all day."

Nursing's ethic of care

Engaging with nurses in this practice environment enabled the author to document nuances of behavior that gave evidence of the nurses' conflicting feelings. It is important to note that nurses are influenced by an ethic of care in their aim to provide assistance that is helpful and good for the patient/family. The American Nurses Association (ANA) ethical code of conduct (2001) provisions 2.1 and 2.2 support the nurse's effort to attempt to resolve conflicts that may occur between the expectations of the healthcare organization plan and the nurse's assessment of what nursing interventions serve the patient's best interest. This includes the nurse's understanding of the uniqueness of the individual patient and the delivery of nursing interventions that meet that need. Nurses who attempt to adhere to these aspects of the ANA Code of Ethics find themselves in the midst of an uncomfortable conflict between contradictory professional aims, namely, care-based therapeutic interventions and the demands levied by the business of health care.

Method

This paper describes the results of a secondary analysis of qualitative data and serves to describe the value of TNIs that PCHNs utilized in practice to meet individualized care needs.

Ethnographic research takes place in the participant's natural setting, where the everyday life of the participants can be shared and the meaning of these experiences can be richly described, thereby contributing to the understanding of phenomena within the cultural context of the participant's world (Bogdan & Biklen, 2007; Geertz, 1973; LeCompte & Priessle, 1993; Macnee, 2004; Stommel & Wills, 2004; Wolf, 2007). It is the insider's or emic perspective that the researcher attempts to comprehend and explicate.

The original ethnographic study of psychiatric community health nursing practice was conducted between August 1, 2000, and July 7, 2001, and employed the traditional methods of ethnographic design, utilizing participant observation methods in field work, many semi-structured interviews, and analysis of agency documents; no patient records were utilized. Details of method and original analysis have been previously published (Sturm, 2004). The settings for data collection included the agency offices, multidisciplinary meetings, in-service meetings, home nursing visits, and time spent with nurses en route between any of these settings. Participants included nine PCHNs, a psychiatric clinical nurse specialist (PCNS), and a variety of multidisciplinary health professionals. All data was collected by the author. Regular meetings with an expert anthropologist guided the collection methods and original analyses.

Ethical considerations

Participant consent, agency permission, and institutional review board (IRB) approval were obtained. The nurses that participated were told that their willingness to allow the author to observe them was voluntary, and that they retained the right to refuse to participate at any time. Agreement stipulated that data obtained would be presented in anonymous and aggregate forms. Observations that included patients were recorded from the standpoint of the nurses' responses and actions and did not contain identifying links to any individual patient. The secondary analysis of original data included in this article is presented in aggregate and composite forms. Any names used in this manuscript are fictitious.

Analysis

A secondary analysis of the field notes was completed, extricating descriptive data from two broad thematic data categories clarified as Issues/Conflicts and Nursing Interventions, which were chosen from the original nine broad thematic categories previously identified (Sturm, 2004). This secondary analysis involved re-reading the portions of the original field notes, which were located by following references and cross-references indexed under the two broad thematic categories and their subcategories. The researcher discovered that the field notes contained rich descriptions of TNIs used in PCHN practice, as well as issues surrounding their use. This evidence was essentially coded and conceptualized to represent nine classification categories identified as TNIs observed in practice (Figure 1).
Figure 1. Secondary analysis process and findings: The nine TNI
classification categories.

Two Broad Thematic Categories (with a combined total of 12
subcategories) Issues/Conflicts

1. Issue: advocacy

2. Issue: autonomy of patient

3. Issue: autonomy of significant other

4. Issue: beneficence

5. Issue/Conflict: many examples

6. Ethical issues

7. Nurse's coping with conflict

Nursing Interventions (home visits & environments)

1. Nursing intervention: therapeutic and "skilled"

2. Nursing intervention: therapeutic, but not reimbursable or
welldocumented

3. Patient's identified benefits of psychiatric nursing visits

4. Environments (office and home)

5. Patient visit situations (all visits)

Nine Newly Identified Classification Categories (derived from
Issues/Conflicts & Nursing Interventions)

Therapeutic Nursing

Interventions (TNIs)

1. Rapport

2. Affirming/Empowerment

3. Reflection

4. Reality Orientation

5. Confrontation

6. Humor

7. Active Listening

8. Modeling

9. Support Sense of Control


Results: TNis and pCHN effectiveness

This section identifies nine classifications of TNIs that were observed in practice and that were extracted from the secondary analysis of seven previously identified sub-categories of the broad thematic category termed Issues/Conflicts and five sub-categories of the broad thematic Nursing Interventions category. Seven of the TNI strategies are aspects of competently executed therapeutic communication techniques. The eighth and ninth strategies include: Modeling, which is identified as a TNI that promotes patient skill development in assertiveness and advocacy; and Support Sense of Control, which is a TNI that supports patient autonomy and self-esteem. Examples of these TNIs, along with evidence of how these TNIs can influence patient outcomes, is presented in the form of qualitative data-based patient care scenarios.

1. Rapport:

PCHN Cynthia Jones explained her insights regarding the need to develop rapport with the patient. "It's very important; just going down a checklist of psychiatric and mental status assessment questions is de-humanizing and interferes with developing a therapeutic rapport. While the assessment is the task of the visit, the relationship is what matters to the patient."

2. Affirmation and Empowerment:

PCHN Anita Smith had a patient with two diagnoses: depression and leg ulcers. She asked her patient to take more responsibility for his wound care by preparing the equipment and removing the dressings before she arrived. Asking a patient to do this is not especially unusual, but what stood out was how Smith clarified the rationale. "It empowers him to take responsibility for some of his care; it gives him more personal strength." The patient's expression and posture demonstrated how positive he felt about this affirmation. This TNI provided an example of holistic PCHN care.

3. Reflection:

Numerous patient-nurse interactions demonstrated reflective communication techniques and evidence of affective caring, which encouraged patients to talk about their feelings directly and to become more aware of those feelings in themselves. One patient was observed speaking to PCHN Jill Roberts. The patient's eyes began to well with tears as she stated, "Talking about my husband and my kids brings up memories." There was a palpable sense of release and emotion (which included feelings concerning her husband's recent death) as the nurse listened to the patient's feelings. This patient suffered from depression and having the intentional nursing support and encouragement to talk about her feelings was an important aspect of her care.

4. Reality Orientation:

Reality orientation as a TNI (as distinguished from the usual issue of a sense of time or place) is another important aspect of therapeutic communication. PCHN Sara Johnson utilized this skill to help a patient, Mrs. Barry, to face some difficult obstacles and to move forward. Mrs. Barry talked a great deal about feeling sad, about having lost interest in her life, and about her fear of going outside (she was agoraphobic). PCHN Johnson directed her to concentrate on the here and now, to think less about broad-based fears, and instead to focus on something positive she could do to get certain services she needed. Mrs. Barry was able to identify someone with whom she was willing to go out of the house as well as another agency that she might call for meals; she also demonstrated success in making a phone call to a doctor. Each time Mrs. Barry faced an obstacle, PCHN Johnson reinforced the choice or helped her to modify the idea. Following the visit, the nurse stated that she did this to build the patient's self-confidence and to help her to see that she could face the problem and do something positive for herself.

5. Confrontation:

Sometimes nurses use the communication technique of confrontation to help patients acknowledge ambivalence between action and feelings, the rationale being that self-awareness enhances growth and autonomy. PCHN Helen Woodbury described her experience with confrontation in relation to a patient, Mr. Perry. When the nurse arrived unexpectedly early for the home visit, she observed Mr. Perry proceeding to yell violently at his wife and to accuse her of not doing certain things he had told her to do. PCHN Woodbury chose to confront the patient with his behavior and the reality of the many helpful things his wife did do for him. Mr. Perry seemed able to acknowledge his behavior, which was a positive step for him. It is likely that meaningful confrontation was possible because the PCHN Woodbury had been working with Mr. Perry for many weeks and had a relationship with him. Confrontation is a technique that is generally avoided until an interpersonal relationship is established with the client (Stuart & Laraia, 2004).

It is important to note here that the nurse was a psychiatric nurse who provided therapeutic communication interventions to a patient who had psychological issues complicated by the nature of his disease, a history of anxiety attacks, and symptoms of a personality disorder, but that the reason she was able to bill for this visit was to provide wound care to the patient. PCHN Woodbury and her supervisor subsequently explained that a psychiatric nurse was assigned to follow this case because other medical-surgical nurses had a great deal of difficulty coping with this patient's behaviors and treatment choices.

6. Humor:

The use of humor as an aspect of therapeutic communication was observed on several occasions. Humor is an intervention that can make the patient feel more relaxed and at ease with the nurse, but it must be appropriate to the individual situation. In a grounded theory study by Scanlon (2006) the use of humor by psychiatric nurses is spoken of as an understated skill and notes that psychiatric nurses use humor as a way to develop a friendly quality, which can develop the therapeutic relationship. This is clearly related to the development of rapport.

Struthers (1999) studied community psychiatric nurse accounts of the use of humor in working with patients and found that the use of humor as a therapeutic skill helped in the development of trust and patient insight, but it was also noted that humor could have harmful effects if the patient perceived it as ridicule. It is necessary for the PCHN to be able to differentiate the use of humor as a beneficial intervention from the use of humor that can be perceived as ridicule. Although humor is classified as a TNI, the use of this skill requires interpersonal expertise and insight, and the extent to which PCHNs possess this skill has not been established. Sometimes humor is used to make one feel more comfortable, but in the patient situations that were observed, the use of humor was intentional and a part of therapeutic communication that supported the rapport between the nurse and the patient. One nurse altered her manner of speech to reflect a lighter style that the patient seemed to enjoy. Another nurse joked about the type and repetition of questions involved in gathering a detailed history. Another nurse used humor when assessing mental status, explaining that whether or not the patient gets the joke can tell her something about the degree of dementia. This, she felt, was better than resorting to repetitious direct questions.

7. Active Listening and Observation:

Active listening and observation on the part of the PCHN is another aspect of therapeutic communication. For active listening to occur, the nurse needs to give full and mindful attention to what the patient is saying, as well as simultaneously observing nonverbal communication. During the home visits many instances of active listening and observation were witnessed. The nurses attentively asked questions and listened to patient responses concerning their experiences of pain, fear, frustration, or need. In one instance with a patient, Mrs. Jones, special skills were clearly required. Many of the things she liked to talk about tended to provoke discomfort in the average person and could be very repetitive. Her ability to communicate was constricted by aphasia, a degree of psychosis, and hypomania. The nurse's ability to listen to Mrs. Jones's concerns with care and intention, but without criticism, was clearly observable and it altered Mrs. Jones's mood for the better. PCHN Lynn Oxford stated that she and her supervisor were talking about whether her visit was a duplication of services, as the patient already visited a psychiatrist once a week. Although this patient saw a psychiatrist for 30 minutes, Mrs. Jones clearly demonstrated a need to be heard and understood beyond that limited session. Mrs. Jones was easily frustrated and social/group daycare situations were intolerable for her. The opportunity to express her thoughts and emotions to her nurse appeared both necessary and therapeutic. This visit did not fall under the usual category of skilled-reimbursable nursing services, and most insurance companies would consider this a duplication of services. PCHN Oxford expressed particular frustration with the lack of Medicare and HMO payment for psychiatric patient visits. Her supervisor stated, "Medical-surgical patients are more often covered for their treatments, it is much more difficult to get reimbursement for psychiatric patients."

Every nurse that participated in this study expressed frustration with the lack of payment for services that they saw as necessary for the welfare of their patients. This scenario illustrates how the competent use of TNIs by the PCHN in providing active listening, assessment, and care is under-recognized and undervalued by third-party payers and is a stressful dilemma for PCHNs.

8. Modeling:

In the field of education, the act of modeling by the teacher is considered by many to be an important aspect of the learning process. Modeling is also a therapeutic strategy to promote assertiveness and advocacy used by PCHNs in practice. It is important to be aware, however, that it takes time to develop sufficient trust and rapport with patients so that when modeling takes place, the patient is interested and open to learning skills that the nurse demonstrates and speaks about. PCHN Kathy Fitzgerald made home visits to Mrs. Diaz, which included modeling interventions provided over time. At the time of data collection, Mrs. Diaz had been PCHN Fitzgerald's patient for 5 or 6 years on the long-term care (LTC) program. Because Mrs. Diaz financially qualified for Medicaid and because she had both complex physical problems and depression, she had been accepted onto the LTC program by the Department of Social Services; it is unusual for a patient with a primary psychiatric diagnosis to be eligible for this type of ongoing care. Patients with chronic depression frequently battle feelings of helplessness. PCHN Fitzgerald demonstrated assertive behavior and was able to teach Mrs. Diaz how to advocate more effectively for her own needs.

The success of this intervention supports the rationale that consistent ongoing assistance with a primary psychiatric nurse in the patient's home setting does support positive change. Mrs. Diaz explained how helpful her nurse had been in straightening out an incorrect phone bill, and she then described how the act of witnessing this process had helped her to follow through on an issue she had a week later with the pharmacy. Mrs. Diaz stated, "Sometimes you need someone like Kathy to get on board and get things straight. You have to be very firm with people sometimes; Kathy can really do that well." After she saw PCHN Fitzgerald stay on the phone for over half an hour with the phone company to get her bill straightened out for her, Mrs. Diaz felt able to persevere with a problem at the pharmacy and was able to succeed in that endeavor independently. Mrs. Diaz sounded proud of her accomplishments. She gained the courage to call her doctor and request a medication change at a later date, without the degree of intimidation she had harbored previously. In this way, PCHN Fitzgerald advocated for the patient and actively modeled behaviors designed to help the patient to self-advocate.

9. Support Sense of Control:

PCHN Marsha Roth conducted a numerical pain assessment with a patient, Mrs. Fine, who suffered from severe arthritis and depression. She responded to Mrs. Fine's answers with a tone of voice that conveyed care and sensitivity. PCHN Roth designed a medication schedule that gave Mrs. Fine more control over the frequency with which she used a medication to control chronic and, at times, severe pain. Mrs. Fine explained during the visit that this worked better for her because she knew she had another pill if she really needed it. Although this patient's condition was chronic, the nurse's interventions assisted the patient in learning ways to cope with her feelings, improve her mood, more effectively manage her mental status, and participate in controlling her physical pain. The reason the nurse could follow this patient consistently, was because she qualified for a Medicaid long-term care program primarily due to her diabetes and advanced age.

Analysis conclusions

This analysis serves to articulate and emphasize the importance of increasing the recognition of the value of TNIs provided by PCHNs. Two major points emerged from the data: Nursing interventions that guide small behavioral improvements or maintain a patient with chronic illness are seldom reimbursed (not valued) by most insurers and, consequently, nurses experience a stressful conflict when they are financially restricted from providing services that they have seen to make a positive difference in patients' lives.

Many of the scenarios demonstrating how TNIs make a difference took place only because these patients had either Medicaid long-term care coverage with mixed medical-psychiatric diagnoses, or other medical issues had made Medicare coverage possible for longer than the common one- or two-visit limit.

In addition, the reimbursement restrictions of third-party payers normally curtail nursing visits to a one- to two-visit time frame. Patient non-compliance and inconsistent adherence with prescribed medication, healthcare regimens, and medical appointments are common complications for persons with mental illness. The unpredictable observable patient behaviors, including hallucinations, delusions, paranoia, confusion, and impulsive, manipulative, or controlling behavior, represent additional obstacles to the delivery of quick teaching interventions that could have any impact on the patient's ability to comply with a therapeutic regimen. This makes it frequently impossible to deliver TNIs with enough ongoing consistency to create a lasting positive outcome.

Discussion

Ethical aspects of the therapeutic relationship

The preceding scenarios provide insights into particular needs and specific characteristics of the PCHN's experience serving a vulnerable population. The identification of specific nursing behaviors utilized in the therapeutic relationship (TNIs) and integrated with aspects of the PCHN role have been presented to document how these specific TNIs, executed by a skilled PCHN, can actually make a difference in the quality of life experienced by persons with chronic mental illness. It is valuable to consider the impact of these TNIs on patient self-esteem, socialization, and capacity for autonomy (Sturm, 2008).

Nursing literature supports creating individualized nursing care approaches for those with mental illness as an effective means to improve self-esteem and socialization (Beeber, Canuso, & Emory, 2004; Seo, Byun, & Kim, 2007; Sturm, 2007). The development of self-esteem in adulthood takes place over time and in connection with relationships that can empower individuals to recognize their own worth. Self-esteem can be fostered and supported through consistent, intelligent psychiatric nursing interventions.

Great skill is required from the nurse in order to engage in a consistent, caring, and intelligent relationship with a person experiencing chronic mental illness. This sensitivity relates back to the philosophical underpinnings characterizing the interpersonal relationship as described by Peplau (1997). A consistent, interpersonal, therapeutic relationship with a nurse has the potential to foster trust and to make guidance acceptable, while demonstrating respect for the rights of the patient. This relationship allows patients to experience themselves as persons whose particular needs are worthy of both acceptance and individualized approaches. Since nurses are educated within a holistic framework of care, they are particularly suited to helping a client to cope with a combination of psychological, spiritual, and physiological needs.

Without consistency and sensitivity, which lay the groundwork for trust in the nurse-patient relationship, guidance can assume a quality of being rigidly imposed. When nurses had only one or two visits, they were observed making efforts to avoid getting too involved, providing quickly delivered instructions, promptly reviewing medications, and performing a mental status assessment to avoid a potential immediate crisis. This left the nurses feeling frustrated, as they lacked the billable time to provide ongoing TNIs in practice. When efforts originally aimed to guide turn into rules that lack the element of human caring, the patient inevitably challenges such rules. Persons with chronic mental illness are quite sensitive in perceiving whether the healthcare provider is offering guidance that is primarily intended to help them to find personally satisfying ways to manage their lives as contrasted with guidance that is designed to efficiently manage an "out of control" person's life according to third-party payer's criteria.

Making TNis reimbursable

Nurses have traditionally sought to meet the needs of vulnerable populations and to advocate for their needs. PCHNs are in a unique position to understand and address the multiple health needs of persons with chronic mental illness. TNIs, which include aspects of the interpersonal nurse-patient relationship, have been articulated as comprising a particular set of skills that enable the PCHN to provide needed healthcare services, deliver caring guidance, support self-esteem, develop socialization skills, and advocate for client autonomy. The fact that TNIs utilized by PCHNs are not considered distinctly billable services by third-party payment systems, when more concrete, medically based tasks such as wound care are, creates an ethical dilemma for the PCHN attempting to provide holistic, quality care to a marginalized population. The care-giving skills and perceptive humanistic responses particular to the PCHN are undervalued homecare services.

A study by Tsai, Chen, and Yin (2005) concluded that a hospital-based homecare model was more cost-effective than a conventional outpatient follow-up model evaluated over a 1-year period. Healthcare services and constraints differ globally; however, this study implies that home visits can be a cost-effective alternative to outpatient clinic type services. In consideration of quality of care, individual rights, and mounting fiscal issues, further research is needed to answer the following question.

If the use of TNIs by PCHNs, as a part of consistent, ongoing home visits to patients with primary psychiatric diagnoses were reimbursed by United States insurance mechanisms, would these patients be managed more effectively within their home and community environments, thereby contributing to an overall decrease in cost of care, with a subsequent decrease in hospital recidivism rates? The PCHNs observed in this study consistently spoke of the good they could accomplish if they were permitted to utilize their skills (TNIs) in providing ongoing, consistent visits to patients with chronic mental illness. The nurses expressed doubt as to whether these skills would ever be recognized for payment and most basically accepted the limitations of the system. Researcher observations of the mood and voice tonality of the nurses demonstrated disappointment and resignation. The dilemma created by restrictions on visits where TNIs are the major skill needed challenges principles inherent in psychiatric professional nursing practice.

Conclusion

The author hopes that articulating the value and nature of TNIs as researched and documented in this particular practice setting will provide impetus for needed healthcare reform and call attention to the value of the skills that psychiatric nurses working in the community can provide through ongoing, consistent, individualized nursing care. Community-based psychiatric nursing services may be feasible alternatives to those institutions, nursing homes, and day programs that are currently used for the management of the needs of persons living in the community with mental illness. The concept of such teams may suggest ways to provide needed assistance that are more humane, individualized, and sensitive to a patient's right to choose to remain in a home environment with ongoing consistent nursing visits when needed.

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Bonnie A. Sturm, EdD, RN

Bonnie A. Sturm is an assistant professor of nursing at Seton Hall University College of Nursing, department of behavioral sciences, community, and health systems, in South Orange, NJ.
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Date:Mar 22, 2009
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MSU launches their new Family Psychiatric Mental Health Nurse Practitioner Graduate Program.

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