A study conducted by the University of Michigan College of Pharmacy found that 28% of low-income pregnant women with HIV are depressed but do not receive adequate treatment. Previous studies have shown that African American women are not only less likely to seek help for their depression, but they very rarely report any symptoms of depression in the first place.
The study involved 431 African American women and 219 white women with depression. Of these women, about 20% reported depressive symptoms, but researchers believe the percentage of depression could be much higher for African American women when compared to whites since the research only found results from women already being treated for depression.
According to earlier studies, African American women are more likely than white women to report physician stereotyping and tend to mistrust the medical community. Studies have shown that African American women do not receive the same quality care as white women; if they were to report signs of depression, they may not be taken seriously. Rajesh Balkrishnan, a coauthor of the study, says physicians have reported feeling unprepared to communicate with minority women regarding depression.
In the future, Balkrishnan believes depression should be screened and treated in pregnant, HIV-positive, minority women. If depression goes untreated in this population, it can sometimes lead to suicide or substance abuse, harming both the mother and baby.
In the press of caring for patients, family nurse practitioners (FNPs) must tend to a patient’s physical well-being and mental health. Caring for a patient’s mental status can be vital to meeting healthcare needs.
As primary care providers, FNPS play a significant role in tending to mental health concerns. The American Association of Nurse Practitioners (AANP) reflected that 88% of the nation’s NP workforce are certified in an area of primary care, with over 70% delivering primary care services, notes LaMicha M. Hogan, PhD, APRN, FNP-BC, associate dean/department chair for APRN Programs for the Texas Tech University Health Sciences Center School of Nursing-Graduate Program.
In this article, we’ll offer ways to ensure you’re attending to your patient’s mental health needs and touch on how FNP programs should educate students about mental health.
Great Impact
Though stigmatizing societal attitudes regarding mental healthcare have improved, a patient’s initial encounter with a healthcare provider will likely have the most significant impact on self-perception of a mental health complaint as well as willingness to seek continued treatment, notesHogan.
Early detection and intervention lead to the best outcomes, in conjunction with a trusting, collaborative rapport between the patient and FNP to reduce stigma present with having a mental health condition, according to Hogan. FNPs must be aware that a patient’s mental health status has a greater impact on chronic physical health conditions if undiagnosed or left untreated, she notes.
It’s imperative for FNPs, especially those in primary care settings, to prioritize the screening of conditions such as depression and anxiety, notes Amanda Ringold, DNP, FNP-BC, CRNP, SANE-A, assistant professor at the University of Pittsburgh School of Nursing. “To ensure effective mental health assessments, FNPs must address and overcome organizational barriers, including time constraints, a lack of a universal screening policy, and providers’ feelings of inadequacy in conducting mental health screenings. FNPs are poised to take on leadership roles within clinical settings to address and mitigate these challenges,” she explains.
Screening Strategies
Various strategies exist for dealing with mental health during patient care visits. For instance,
Ringold notes that not every screening needs to be done face-to-face with the FNP. Instead, screenings can be conducted with pen and paper in the waiting room or via an app before the appointment. She notes that other team members, including nurses or medical assistants, can be trained in administering the screenings.
Lisa Johnson, DrNP, CRNP, ACNP-BC, associate professor and DNP/NP Program Coordinator at Gwynedd Mercy University, agrees that patients can complete questionnaires in the waiting room or before the visit. However, “we have to be cautious not to fatigue patients with questionnaires and to ascertain their reading level and primary language prior to requesting a mental health assessment be completed by the patient,” she warns.
In an interview, Irene W. Bean, DNP, FNP/PMHNP-BC, FAAN, FAANP, FNAP, CEO of Serenity Health Care, P.C., and Tennessee State Rep for AANP, says to pay attention to a patient’s body language once in a patient encounter. Watch for poor eye contact or note whether a patient has been crying.
She says to pay attention to slurred speech and be aware of signs such as a patient who typically speaks loudly suddenly speaking in a whisper or a normally talkative patient now being reserved.
FNP Programs
Johnson says NP educational standards emphasize assessing mental health in varied patient populations. Healthcare providers and institutions of higher education need to focus on the cultural considerations of mental health disorders and further emphasize collaborative communication between primary care and mental health providers, she notes.
Hogan says clinical competencies are best attained via a competency-based educational model throughout the FNP curricula. Specialized courses on mental health, simulation training, interprofessional education, and clinical rotations in primary care settings can develop competence. She says that after graduation, FNPs should maintain continuing education specific to FNP’s scope of practice and evidence-based care for mental health concerns.
Ringold notes a growing trend of students at the University of Pittsburgh School of Nursing opting for dual FNP-PMHNP degrees.
Scope of Practice
While FNPs can treat mental health conditions such as basic anxiety and depression, they need to be mindful of their state’s scope of practice, says Bean. For patients with conditions such as bipolar disorder or schizophrenia, you may be stepping outside your practice scope and may need to refer the patient to a specialist, Bean says
“One thing that I would stress, and I stress to my students, is that you want to protect your license. You want to ensure the patient is safe while protecting your license,” Bean says.
Calling on Compassion
When you realize your patient is anxious, depressed, or dealing with a mental health issue, “What you don’t want to do is rush that patient from that conversation,” says Bean. “You’re going to miss a lot of things when you rush patients who have a mental health crisis through your clinic,” Bean says.
“You have to have compassion for patients dealing with a crisis. Their crisis may not be something you feel is a crisis, but to them, it’s everything. You can’t discount their feelings, and you can’t discount what you’re seeing in that patient.”
Nurse practitioners (NPs) are essential healthcare providers who are excellent, skilled clinical resources for newborns and elderly patients. While there are many available NP career choices, the family nurse practitioner (FNP) is a trendy option among nurses seeking to become primary care providers with the authority to diagnose illnesses, order diagnostic tests, prescribe medications, and manage the care of patients across the lifespan.
If you’re a nurse who wants to become a family nurse practitioner, what does that avenue look like, and what hoops do you need to jump through to achieve your goal? And if you’re not a nurse, what additional work must be done to get there? Let’s examine the landmarks along the way to becoming an FNP.
Why Become an FNP?
Becoming an FNP has pros and cons, so considering the many possibilities available in advanced practice nursing, it’s prudent to do your due diligence.
PROS:
Earning power: According to the U.S. Bureau of Labor Statistics (BLS), nurse practitioners, nurse midwives (CNMs), and nurse anesthetists (CRNAs) earned a median annual salary of $125,900 in 2022, with a mean hourly wage of $60.53. While the much higher salaries of CRNAs may admittedly skew the numbers higher, there’s no arguing that NPs are doing well for themselves.
Job growth: As another incentive for those considering the NP path, the BLS projects 38% job growth for NPs through 2032. When weighed against projected job growth of 6% for RNs and 3% for MDs, the attractiveness of a career as an NP can appear exceptionally bright.
Full practice authority: The state practice environment for NPs is improving slowly. The American Association of Nurse Practitioners (AANP) reports that in the states where full practice authority has been granted, “state practice and licensure laws permit all NPs to evaluate patients; diagnose, order and interpret diagnostic tests; and initiate and manage treatments, including prescribing medications and controlled substances, under the exclusive licensure authority of the state board of nursing. This is the model recommended by the National Academy of Medicine, formerly called the Institute of Medicine, and the National Council of State Boards of Nursing.”
CONS:
Future license portability: At some point in the future, the APRN Compact will become a reality like it is for millions of registered nurses. However, more states still need to sign on to begin implementing even a fraction of a potential compact.
Stress and burnout: Recent statistics show a high level of burnout, depression, and anxiety among NPs, primarily due to workplace stress, overwork, perceptions of lack of respect from colleagues and patients, and insufficient salaries.
The 15-minute visit: Since most FNPs work in a clinic or office setting, the now common 15-minute office visit can starkly contrast with the relational aspects of bedside nursing that many nurses enjoy as RNs.
The FNP Career Pathway
For Non-nurses:
For non-nurses wanting to secure their future by becoming a family nurse practitioner, the first step is to become an RN through an associate degree in nursing (ADN) program or a bachelor of science in nursing (BSN) program.
Alternatively, a non-nurse can also pursue a direct-entry MSN program, an accelerated path where the student simultaneously earns a BSN and an MSN. Specific direct-entry programs bypass the BSN entirely. Most of these programs will require the completion of prerequisites that will likely include some combination of anatomy and physiology, biology, chemistry, nutrition, sociology, psychology, statistics, and microbiology.
For Registered Nurses:
Registered nurses with an ADN who want to pursue a career as an FNP will want to complete an RN-to-BSN bridge program and then apply to an MSN program with an FNP track. Registered nurses can also consider an RN-to-MSN program, which allows students to take core BSN courses while completing their MSN.
Potential MSN and FNP students should know there is a strong movement afoot to make the Doctorate of Nursing Practice (DNP) degree the entry-level requirement for becoming a nurse practitioner. While a goal of 2025 has been set, this change has yet to be codified as an absolute requirement, but the day for such a requirement is fast approaching.
Students can expect to be tested regarding aspects of assessment, diagnosis, planning, and evaluation of patients across the lifespan in areas of knowledge that include:
Health assessment
Pathophysiology
Therapeutics
Evidence-Informed Practice
The Life of the FNP
Licensed and certified family nurse practitioners can work in a wide variety of settings, including but not limited to:
FNPs can earn additional postgraduate certifications in areas like psychiatric/mental health. APRNs can also become eligible for leadership positions in many clinical settings.
While those considering FNP certification may be worried about the limits of the increasingly common 15-minute patient visit, FNPs can find plenty of practice areas with other types of structures for patient interaction.
With predictions for astronomical job growth and opportunity in the years to come, family nurse practitioners will undoubtedly be in great demand nationwide. Pursuing the career path of the FNP is not for everyone, but the plethora of potential opportunities will attract students from all walks of life far into the foreseeable future.
Exposure to traumatic stress can have a life-altering negative impact on student nurses. Traumatic stress can challenge effective coping, emotional regulation, and the ability to focus, retain, and recall nursing concepts. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), the “3 E” conceptualization of trauma are Event (single or cumulative), Experience (neglect, abuse, betrayal), and Effects (anxiety, loneliness, depression, feeling unsafe ) are manifested in various ways in people with exposure to trauma.
An individualized student-centered approach is crucial in understanding and adapting teaching pedagogy in nursing education to realize, recognize, respond, and resist re-traumatization (SAMHSA, 2014)in student nurses with a history of traumatic stress.
This article discusses the concept of trauma-informed pedagogy in nursing education and its significance in promoting equity and inclusion. Trauma-informed pedagogy suggests that past experiences can negatively impact health outcomes and learning (Garfin D. R. et al., 2018). As a result, educators must be able to identify signs of trauma and adapt their teaching methods to meet their students’ unique needs. It discusses the impact of trauma on nursing students’ physical and mental health functioning, and it then delves into implementing principles of trauma-informed pedagogy in the classroom.
Background/Significance
Trauma is defined as an event or set of circumstances that an individual experiences as physically or emotionally harmful or threatening, resulting in lasting adverse effects on their functioning and well-being (Bremner, J. D. 2006). College students, despite their excitement to succeed, often experience severe psychological distress, with 70% reporting such distress. Additionally, 35% of students were diagnosed with anxiety, and 29% had depression (American College Health Association, 2022).
Transgender and LGBTQIA students report higher levels of mental health issues than their straight counterparts. Microaggressions are also experienced by underrepresented students, creating a sense of unsafety on campus. Evidence suggests that Colleges should pivot to a learning space that promotes inclusion and equity. Only 40% of college students think colleges are doing enough to support mental health (Veneable, M.A., & Pietrucha, M. E., 2022).
The Universal Design for Learning ( UDL) recognizes that every student has different learning needs, and a one-size-fits-all approach is an ineffective instructional strategy. Similarly, implementing trauma-informed pedagogy principles within the nursing curriculum is a significant step toward meeting every student’s learning needs and experiences, promoting accessibility, equity, and inclusion in nursing education.
How Traumatic Stress Affects the Brain
Traumatic experiences can affect the brain’s development, structure, and function. It is critical to understand normal brain development to distinguish brain abnormalities. The areas of the brain responsible for stress responses are the amygdala, hippocampus, and pre-frontal cortex (Bremner, J. D., 2006). When an individual is exposed to traumatic stress, there is an increase in the level of cortisol and norepinephrine. Repeated exposure to stress increases the level of cortisol and norepinephrine and affects normal brain functioning and stress regulation, resulting in pathophysiological change(Bremner, J. D. 2006).
Students who are affected by traumatic stress may have difficulty learning concepts, focusing, and retaining information, resulting in course failures and higher attrition rates compared to their peers who have not experienced trauma. Traumatic experiences can cause anxiety and depression in some students. Past and current data suggest that trauma-informed care is critical for the promotion of equity in people with a history of trauma (Han et al., 2021).
Students’ sense of safety is disrupted, and the cumulative effects are difficulty adjusting to college experience, low grades, and high attrition rates. According to (Corello J., 2018), educators should adopt trauma-informed teaching and be compassionate and consistent in the learning environment. Despite the impact traumatic experience has on the brain, there is hope and possibility for students to be successful.
Implications for Nurse Educators
In the Four “Rs in the Trauma-informed approach to teaching student nurses(SMASHA, 2014), the nurse educator must convey empathy, possibilities, and hope to student nurses and focus on “what happened to you, instead of what is wrong with you’. Implementing trauma-informed principles is an issue of equity and inclusion and must be viewed through the lens of disability.
Realization
Research suggests that 66%-85% of youth report exposure to traumatic events by the time they enter college (Read et al., 2011). Additionally, approximately three-quarters of college students, 77 %, experienced moderate to severe psychological distress (ACHA, 2022). Understanding that traumatic experiences can affect the development, structure, and function of the brain, the nurse educator must acknowledge that trauma happened and provide a trusting teaching environment that emphasizes hope and transformation.
Realizing that trauma affects the student’s ability to function optimally, the nurse educator must stay involved in world events that may be traumatic to students: for instance, racism, disability, COVID-19, sexism, sexual harassment, and sexual orientation. Modeling emotional intelligence skills, self-reflection, and situational awareness, the nurse educator can convey trust and transparency when discussing and understanding sensitive topics in the classroom.
Recognize
The nursing process is a framework taught in nursing education to provide care for diverse populations. It begins with an assessment. Likewise, the nurse educator must be able to recognize signs of traumatic stress and respond with empathy, kindness, and understanding. Some signs and symptoms are difficulty focusing on a topic, lack of engagement, absenteeism, anxiety, low grades, and difficulty adjusting to the college environment.
It is essential to acknowledge that the traumatic event happened, and an evidence-based action plan is activated to promote healing and agency to enhance academic success. The nurse educator must be knowledgeable about topics or events that may trigger traumatic stress and develop a lesson plan or teaching strategies to avoid triggers—for instance, disparities in healthcare outcomes for minorities. Nurse educators must adopt several strategies to effectively support students’ learning experiences in teaching sensitive topics. To this end, the nurse educator should consider the value of establishing eye contact with students and facilitating opportunities for them to share their lived experiences. The nurse educator must also demonstrate a genuine interest in the student experience. By applying these strategies, nurse educators can foster an environment that supports students’ learning journey and promotes their well-being.
Respond
When a student goes through a traumatic experience, their sense of safety can be severely affected. As a nurse educator, it is essential to demonstrate emotional intelligence while conversing with such students regarding traumatic stress. Using the student’s name and giving them enough time to contemplate and respond is crucial. In addition, the nurse educator should offer their presence to show kindness and compassion, which can provide comfort and support for the student.
As a nurse faculty member, you can support your student’s academic journey by referring them to the Office of Accessibility and Disability. The office provides essential services to students with disabilities, ensuring they have the resources to succeed in their studies. Letting your students know you are available for office hours and phone calls is essential, as this can help them feel more comfortable and supported.
Creating a respectful and inclusive learning environment is crucial to the success of all students. You can do this by promoting a culture of civility and respect in your classroom and being mindful of your students’ diverse needs. If a student is experiencing anxiety or stress, consider extending assignment due dates to help alleviate their concerns.
Finally, it is essential to recognize that some students may have a history of trauma that could impact their ability to learn. To increase the accessibility and inclusion of these students, incorporate multiple teaching modalities that address the cognitive, psychomotor, and affective domains of learning. Doing so can help ensure that all your students can succeed.
Resist re-traumatization
In a nursing education culture that prioritizes diversity, equity, and inclusion, it is essential to recognize that some college students may have experienced trauma. By intentionally incorporating transformative, trauma-informed practices into nursing education, we can foster a sense of human dignity, promote academic growth, and help students thrive. To prevent re-traumatization, faculty and peers must have zero tolerance for discrimination against students. The learning environment must prioritize civility, human caring, compassion, and consistency (Corello, 2018) while avoiding punitive measures and implementing clear policies and procedures. Sensitive topics should be approached with empathy and understanding, and training modules focused on trauma and its effects can help create awareness and build a strong sense of community.
Conclusion
Integrating trauma-informed practices into nursing education requires comprehensive changes across multiple levels, from micro to macro systems. At the micro level, nurse faculty must demonstrate empathy, benevolence, courtesy, and honor towards individuals who have survived trauma. They must also remain watchful in recognizing, validating, and averting re-traumatization for student nurses who have experienced trauma. By nurturing a learning environment that fosters personal development and transformation, faculty and students can collaborate to establish a warm and accommodating community open to everyone.
References:
1. American College Health Association -National College Health. (2022). Assessment III: Undergraduate Student Reference Group Executive Summary Spring 2022. Silver Spring, MD: American College Health Association.
2. Bremer, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445-61.
3. Carello, J. & Thompson, P. (Eds). (2021). Lessons from the pandemic: Trauma-informed approaches to college, crisis, change. Palgrave Macmillan.
4. Garfin, D. R., Thompson, R. R., & Holman, E. A. (2018). Acute stress and subsequent health outcomes: A systematic review. Journal of Psychosomatic Research, 112, 107-113. doi: 10.1016/j.jpsychores.2018.05.017
6. Han, H. R., Miller, H. N., Nkimbeng, M., Budhathoki, C., Mikhael, T., Rivers, E., Gray, J., Trimble, K., Chow, S., Wilson, P. (2021). Trauma-informed interventions: A systematic review. PLoS One, 16(6), e0253209. Doi: 10.1371/journal.pone.0253209
7. Kubala, J. (2020). Of Trauma and Triggers: Pedagogy and Affective Circulations in Feminist Formations, 32(2), 183-206.
8. Read, J. P., Wardell, J. D., Vermont, L. N., Colder, Ouimette, P., & White, J. (2012). Transition and change: Prospective effects of posttraumatic stress on smoking trajectories in the first year of college. Health Psychology, 32(7), 757-767.
9. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. (2014). HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD.
10. Veneable , M. A., & Pietrucha, M,E. (2022). 2022 College Mental Health Report, Best Colleges.
There are countless reasons why some of us fall into nursing. And when we choose this particular professional journey, all types of motivations keep us in the game.
For many of us, a family member who was a nurse inspired us to continue the tradition. For others, it was witnessing the nursing care of a sick or dying loved one that opened our eyes. For still others, nursing seemed like a flexible, well-paying job that could support a family, especially since nurses will always be needed (until the robots take over).
But we all change, as do our lives, and this begs the question: if the nature of your life and your reasons for being a nurse change over the years, how do you continue to find meaning in what you do?
How it all Began
You became a nurse because your grandmother and mother were both nurses. Your grandmother told fascinating stories about being a nurse during World War II, with air raid sirens, soldiers missing limbs, and lives lost and saved all around her. Your mother also had good stories, though maybe not as romantic as grandma’s.
You could have finished high school and gone to nursing school, launching your career at 22. Or your story might involve, like yours truly, spending your twenties doing all sorts of different jobs and arriving at nursing in your early 30s when you had a family to support and a pre-adolescent son to set a good example for. And there are also those who come into nursing after an entirely different career: FBI agent (a true-to-life story I recently heard firsthand), accountant, office manager, etc.
No matter how you find your way, you have a story that includes the motivations that led you there. Maybe you truly felt a calling, or perhaps you just needed a reliable job. Whatever the vehicle, it delivered you to the door. But what happens when that original vehicle eventually pulls out of the parking lot, and you’re left wondering why you’re still here?
When the Sands Shift
The sands of your life can shift for many reasons: having children, getting married or divorced, finding a new passion, aging, getting bored, or moving to a new state or country.
The sands of your career and the healthcare industry can also change. Here are some observations I’ve heard from nurses I’ve spoken with:
Healthcare is becoming more corporatized, and the healthcare business feels more focused on money than human beings.
The bullying and incivility at work is terrible and demoralizing.
Unsafe staffing consistently puts our licenses at risk.
And the list goes on.
What do you do When things change— inside of you, in the world around you, or likely both? If your motivations for being a nurse feel different than they used to, you’re not alone. And if you’ve lost your motivation and passion entirely, how do you continue?
Acknowledging and Accepting Change
For some nurses, when the world shifts around them, they bury their heads in the sand, perhaps doing okay for a while. Others become bitter, burnt out, and resentful, and may themselves become bullies who make the lives of those around them miserable. Either that, or they fall into depression, anxiety, or addiction.
You may also arrive at a place where your kids have left the house, and you have the freedom to explore. You can study massage therapy, learn astrology, write a book, or become a podcaster. It’s all valid, and the world is essentially your oyster.
But the original question remains: how do you continue to find meaning in your actions?
Much of this comes down to your core values. The Barrett Personal Values Assessment and the Schwartz Portrait Values Questionnaire are both valid tools for identifying your values. You can also work with a mentor, faith leader, therapist or counselor, career coach, or other trusted individual to help you uncover what’s currently most important to you.
Aside from your values, you also need to examine the current state of your life:
What are your needs?
How have the nature of your home life and relationships changed?
Do you have more people dependent on you, or are you more independent than ever?
Has your health changed over the years? Do you have less physical stamina? Have you developed chronic illnesses?
Acknowledging the changes in your life, your family structure and relationships, your body, and the world around you is one of the keys to examining what’s currently making you tick and how to continue.
Based on what’s changed over the years, there may be a way for nursing to continue to be a natural fit, but you may also find that nursing no longer offers the fulfillment it used to. Being honest with yourself is an excellent place to begin since a critical assessment of your life and career must start with clarity.
As you examine your values, the current state of your life, the things that feel important to you, and your needs, things will become more apparent.
If you began your nursing career because of grandma’s inspiring stories but now find that the inspiration is no longer there, it’s not shameful to acknowledge the truth and seek other career options. And if nursing is now simply a job and no longer feels like the calling it once was, you may still be able to continue.
However you move forward, keep in mind that change is the only true constant, and the path that you once traveled may need some readjusting. Be patient, have self-compassion, and forge ahead towards whatever the future may hold.
