Penn Nursing JOSNR 2013

Vol 6 Issue 1

2012 - 2013

Mental Health

JOSNR

Table of Contents Ethical Perspectives Regarding Antidepressant Drug Therapy During Pregnancy

SCOTT C. SCHMIDT ------------------------------------------------------------- 1 - 3

The Impact of Informational Materials on Psychosocial Responses to HPV Diagnosis and Management

JOSELLE PALACIOS------------------------------------------------------------- 4 - 10

The Implications of Change on Advanced Practice Psychiatric-Mental Health Nursing

SCOTT SCHMIDT ---------------------------------------------------------------- 11 - 16

The Birth of an Intersex Infant: Exploring the Options and Ethics Behind Decision-Making

DANA OVADIA--------------------------------------------------------------------- 17 - 20

Prenatal Care for Women with Serious Mental Illness

MARISSA DECESARIS---------------------------------------------------------- 21 - 23

The Physical and Mental Health Effects of Community Violence Exposure in Pre-Adolescent and Adolescent Youth

SARAH FAIRBROOK----------------------------------------------------------- 24 - 30

Ethical Perspectives Regarding Antidepressant Drug Therapy During Pregnancy Scott C. Schmidt, BA, BSN, RN Abstract A literature review was conducted to evaluate and understand the effects of antidepressant medication during pregnancy and the ethical issues surrounding the topic. Through the discussion of three articles, the review weighed the effects of antidepressants on maternal and child health. Antidepressant medication during pregnancy poses relative risks to cause fetal complications and defects, though the risk remains very small. However, untreated depression may significantly impact the childbearing family, including premature births, low birth weights, miscarriages, and suicide. Clinicians often have misconceptions of the risks of untreated depression during pregnancy and could benefit from an increased understanding of the current literature when making treatment decisions. Nevertheless, an individual’s history, symptomatology, and an understanding of medications known to be harmful to the fetus should guide the choice of treatment. Further research may help solidify understanding among clinicians and the public and ultimately lead to improved health outcomes for both mother and child.

Ethical Perspectives Regarding Antidepressant Drug Therapy During Pregnancy

Depression affects one quarter of women during pregnancy (Cohen et al., 2006). Clinical trials have demonstrated that medication and psychotherapy are effective as stand-alone forms of treatment for depression, yet a combination of the two treatment options provides the most sustained response. But how does pharmacological treatment impact the fetus?

Furthermore, what are the impacts of not treating the pregnant woman? These are just a few of the questions that this paper will explore while examining the ethical issues surrounding the use of antidepressant drug therapy during pregnancy.

Antidepressant Medications During Pregnancy

Care must be taken when prescribing any medication during pregnancy and an evaluation of the risks and benefits to both the mother and fetus must be considered. When life-threatening situations arise and require immediate intervention during pregnancy, it is common for “emergency” medications to be used.

However, with conditions that pose less of an immediate threat to life, such as depression, medications are prescribed with greater hesitation (Payne &MeltzerBrody, 2009). The body of literature suggests that common medications used to treat depression contribute to an increased risk including fetal heart defects, limb malformation, and persistent pulmonary hypertension of the newborn (Malm, Artama, Gissler, & Ritvanen, 2011). Conversely, recent research indicates Vol 6, Iss 1, 2012-2013

that the likelihood of birth defects after prenatal exposure to certain psychiatric medications are not as great as earlier studies had estimated (“Prescribing During Pregnancy,” 2008).

An Ethical Issue

The ethical question is whether or not to take antidepressant medications during pregnancy. Research indicates that antidepressants pose an increased risk to the fetus. The research reviewed also indicates that untreated depression during pregnancy increases the rates of preterm births and substance abuse, both of which pose an increased risk to the fetus and the mother. Thus, one must evaluate the risks and benefits in attempting to resolve the ethical situation.

The Effects on Maternal and Child Health

The article “Prescribing During Pregnancy” (2008) from the Harvard Medical School’s Harvard Mental Health Letter states that all psychiatric drugs cross the placenta and reach the developing fetus, and some increase the risk of certain congenital malformations. Furthermore, Cohen et al. (2006) found that of 201 women with a history of Major Depressive Disorder (MDD), 68% of those who stopped taking antidepressants after becoming pregnant suffered a relapse of depression, compared to a 26% incidence of relapse in those who continued taking their antidepressants. Antenatal depression has been associated with low maternal weight gain, increased rates of preterm birth (Li, Liu, & Odouli, 2009), increased ambivalence about the pregnancy and overall worsened health (Orr, Blazer, James, & Reiter, 2007). Additionally, prenatal

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exposure to maternal stress has demonstrated consequences for the development of infant temperament (Davis et al., 2005).

Literature Review Antidepressant Use During Pregnancy: Current Controversies and Treatment Strategies

In this article, Payne and Meltzer-Brody (2009) examined the risks and benefits of antidepressant use during pregnancy. Initially addressed is the “common misconception” that MDD is “different from, and not as serious as, medical illness.” This often results in inappropriate discontinuation of antidepressants during pregnancy. Payne et al (2009) asserted that continuation of medication should revolve around symptomatology, where patients with mild MDD might discontinue therapy and more severe MDD may benefit from continued therapy due to known risks of untreated depression.

Next, the authors discussed how the literature offers limited evidence to guide clinical practice regarding antidepressant therapy in the pregnant woman and the inability to randomly assign depressed pregnant women in clinical trials and the resultant unknowns from limited data. They also referred to the limited helpfulness of the FDA Pregnancy Categories, including that “1) the FDA categories do not address dosing; 2) lack of consideration of time of exposure to the medication; and 3) excessive reliance on animal data and lack of human data” (Payne and MeltzerBrody, 2009). The authors concluded that the safety of antidepressant use during pregnancy appears to be reassuring, however state that two topics remain unclear: neonatal withdrawal syndrome and primary pulmonary hypertension of the newborn (PPHN).

SSRI during pregnancy and risk of persistent pulmonary hypertension in the newborn

Kieler et al. (2012) showed that exposure to SSRI late in pregnancy was associated with an increased risk of PPHN. Specifically, they concluded that the risk was double that of the general population. This translates to 3 babies in every 1000 born having PPHN versus 1 in every 1000 in the general population. It should be noted that although this is an increased risk relative to the general population, the overall risk is relatively low. Furthermore, there are other known causes of PPHN including asthma, diabetes, and obesity. These factors were not part of the exclusionary criteria for analysis in the study and thus it is difficult to determine if it was the medication or these other medical conditions that affected the data.

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Prenatal drug exposure and an untreated psychiatric disorder both present risks

This article reviews the risks of both prenatal psychotropic drug exposure and untreated psychiatric disorder, though the primary focus of this publication was antidepressants and specifically SSRIs. An antidepressant that should not be used during pregnancy is paroxetine because it might increase the risk of several types of rare congenital heart defects if used during the first trimester. Furthermore, when used during the last trimester of pregnancy, SSRIs as a class of medications that demonstrate temporary problems in as many as 25% of newborns, with common symptoms of tremors, restlessness, mild respiratory problems, and weak crying. “Prescribing During Pregnancy” (author, 2008) reveals that “in most cases, these symptoms disappear in the first few days after birth, although some infants are admitted to the neonatal intensive care unit as a precaution.”

Putting Theory into Practice Recommended Changes in Practice

Based on the current research regarding antidepressant use during pregnancy, [as future clinicians, it is important to think of developing evidence based guidelines that address the needs of this vulnerable population] {my initial goal as a nurse would be to work to create evidence-based guideline.}guidelines.

By creating guidelines for the use of antidepressants during pregnancy, clinicians may provide increasingly consistent information and care to pregnant women.

Though additional research will solidify treatment approaches based on looming questions, the literature does offer a start to creating guidelines. First, medications that are known to cause fetal harm should not be used. Second, an establishment of treatment criteria based on the severity of the symptoms should guide usage. Third, the guidelines should include information about the risks of abruptly stopping medication and the increased risk of usage of medication late in pregnancy. A nurse may immediately implement all of these into practice to educate, support and inform patients, leading to improved levels of care. Furthermore, attempts to increase awareness of clinicians by hosting educational meetings and journal clubs may ensure that care reflects the current literature. Challenging the misconception that MDD during pregnancy is relatively benign to the fetus and woman serves as a starting point to enhancing clinical options and outcomes.

Barriers to Recommendation

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Challenges and barriers exist in implementing these recommendations. Challenges include the willingness of the clinical team to acknowledge and accept the literature enough to motivate change in their practice. Furthermore, a comprehensive meta-analysis of the literature needs to be synthesized to create a more uniform understanding of and therefore trust in the treatment of pregnant women with MDD. Barriers that exist include limited knowledge regarding fetal risk of untreated MDD in pregnancy, and the short and long-term risks to the fetus of antidepressant exposure during pregnancy. Confronting these issues remains difficult because research involving pregnant women in placebo-controlled trials is currently protected.

Conclusion and Opinion

To best determine the choice of treatment, the nurse should use the current literature to guide practice. This includes educating the patient on the risks with a nomenclature that is not misleading. For example, the research shows that using SSRIs during the late stages of pregnancy increases “relative risk” of PPHN and is (statistically) “significant.” This could imply a false risk versus the truth: that the risk goes from 1 in 1000 births to 3 in 1000 births. Therefore, as additional information becomes available and eventually resolves conflicting information regarding the use of antidepressants, the better choices clinicians and patients will have. Thus, it is important that researchers receive adequate funding so that clinicians may better understand the risks and benefits of utilizing antidepressant medication as a treatment option during pregnancy.

References Cohen, L. S., Altshuler, L. L., Harlow, B. L., Nonacs, R., Newport, D. J., Viguera, A. C., . . . Stowe, Z. N. (2006). Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA: The Journal of the American Medical Association, 295(5), 499507. doi:10.1001/jama.295.5.499 Davis, E. P., Glynn, L. M., Dunkel, S. C., Hobel, C., Chicz-Demet, A., & Sandman C. A. (2005).

Corticotropin-releasing hormone during pregnancy is associated with infant temperament. Dev Neurosci, 27(5), 299–305.

Einarson, A. (2009). Comment on campagne “fact: Antidepressants and anxiolytics are not safe during pregnancy”. European Journal of Obstetrics, Gynecology, and Reproductive Biology, Vol 6, Iss 1, 2012-2013

142(2), 163; author reply 163. doi:10.1016/j. ejogrb.2008.09.016 Helle Kieler, Miia Artama, Anders Engeland, Örjan Ericsson, Kari Furu, Mika Gissler, . . . Bengt Haglund. (2012). Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: Population based cohort study from the five nordic countries. BMJ, 344 doi:10.1136/bmj.d8012 Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms during early pregnancy and the risk of preterm delivery: a prospective cohort study. Hum Reprod, 24(1), 146–153.

Lindahl, V., Pearson, J. L., & Colpe, L. (2005). Prevalence of suicidality during pregnancy and the postpartum. Arch Womens Ment Health, 8(2), 77–87.

Malm, H., Artama, M., Gissler, M., & Ritvanen, A. (2011). Selective serotonin reuptake inhibitors and risk for major congenital anomalies.

Obstetrics and Gynecology, 118(1), 111-120. doi:10.1097/AOG.0b013e318220edcc Mangin, D. (2009). Women should give informed consent before starting SSRIs. BMJ (Clinical Research Ed.), 339, b4292. doi:10.1136/bmj.b4292 Prescribing during pregnancy. prenatal drug exposure and an untreated psychiatric disorder both present risks. (2008). The Harvard Mental Health Letter / from Harvard Medical School, 25(6), 1-3.

Orr, S.T., Blazer, D. G., James, S. A., & Reiter, J. P. (2007). Depressive symptoms and indicators of maternal health status during pregnancy. J Womens Health, 16(4), 535–542.

Sit, D., Perel, J. M., Wisniewski, S. R., Helsel, J. C., Luther, J. F., & Wisner, K. L. (2011). Motherinfant antidepressant concentrations, maternal depression, and perinatal events. The Journal of Clinical Psychiatry, 72(7), 994-1001. doi:10.4088/ JCP.10m06461 Wendland, C. (2010). Risky business. The Hastings Center Report, 40(4), 7-8.

Zuckerman, B., Amaro, H., Bauchner, H., & Cabral, H. (1989). Depressive symptoms during pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol, 160(5 Pt 1), 1107–1111.

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The Impact of Informational Materials on Psychosocial Responses to HPV Diagnosis and Management Joselle Palacios, RN, BSN Abstract Cervical cancer screenings, colposcopy, and a diagnosis of human papillomavirus (HPV) increase anxiety in clients. Researchers have investigated several interventions to reduce emotional distress in clients, including disseminating informational leaflets and brochures, offering educational and counseling services, and hypnotherapy. There is insufficient evidence, however, for the effectiveness of informational leaflets in reducing anxiety and improving knowledge and client satisfaction. This article examines the utility of such an intervention and explores ones that may be more effective in reducing anxiety prior to, during, and after HPV and cervical cancer screening and management. Because HPV follow-up can involve several steps that take place over approximately two years, it is important to keep clients engaged in the system along the way. This article also examines if informational interventions increase client knowledge of cervical cancer and its cause, HPV and what impact this has on follow-up.

The Impact of Informational Materials on Psychosocial Responses to HPV Diagnosis and Management

Several studies have linked HPV diagnosis to feelings of shame, anxiety, depression, and isolation (Maggino et al., 2007). Additional layers of distress are added due to fear of pelvic and other gynecologic exams, transmitting the infection to sexual partners, and social stigma (Maggino et al., 2007). Additionally, because of the various levels of HPV diagnoses that may require anything from watchful management to invasive treatments, such as loop electrosurgical excisional procedure (commonly known as LEEP), the confusion over diagnosis also contributes to emotional distress (Daley et al., 2010). Not only does confusion lead to negative emotional response, it also may decrease follow-up rates (Daley et al., 2010). Factors as wide-ranging as baseline levels of anxiety prior to diagnosis, ethnicity, and smoking status all play a role in the presence of emotional distress following HPV diagnosis (Johnson, Sharp, Cotton, Harris, Gray, & Little, 2011). One study found that women who are single, have children, have high trait anxiety, and anticipate fear and pain prior to procedures are at greatest risk for distress due to colposcopy (Kola & Walsh, 2011).

Due to the high incidence and complexity of anxiety and emotional distress in response to HPV diagnosis, clinicians and researchers have investigated the most effective psychosocial interventions. One of the most commonly used interventions in the clinical Vol 6, Iss 1, 2012-2013

setting is informational written materials, such as brochures, leaflets, and posters. In fact, due to the fact that many clients may only receive written information from their clinician without any face-to-face discussion, it is critically important to study the impact of these materials on clients’ lives. This article examines the effectiveness of this intervention in reducing anxiety and keeping clients engaged in the long follow-up process associated with HPV.

The evidence is mixed as to whether such materials increase knowledge about the medical aspects of HPV and decrease anxiety. A 2008 Australian study found that anxiety is increased in women with an HPV diagnosis when they receive less knowledge about HPV (Hall, Howard, & McCaffery, 2008). Several other studies, however, have found that informational interventions alone did not significantly decrease anxiety. One study even found that psychosexual problems actually increased with the dissemination of information leaflets prior to colposcopy (Howells et al., 1999).

Clients report wanting information about HPV but the ways in which information is presented often is problematic. For instance, written materials may overemphasize medical information and neglect the psychosocial impact of an HPV diagnosis (Hall et al., 2008). Additionally, most informational materials focus on treatment options despite the fact that most women with an abnormal Pap smear result will not require treatment, thus skewing the lived experience of most women with HPV (Hall et al., 2008). Finally, Journal of Nursing Student Research

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most clients perform their own research about HPV online and clinicians need to be aware of the most accurate online resources so that they may refer clients to them (Perrin et al., 2006).

The Burden of HPV

There are more than 120 identified strains of HPV, approximately 40 of which can infect the genital tract of men and women (Association of Reproductive Health Professionals, 2009). As of 2012, the Centers for Disease Control and Prevention (CDC) estimates that nearly 20 million Americans are infected with HPV and 6 million new cases are diagnosed annually (CDC, 2012). Nearly 50% of all sexually active Americans have HPV infections (CDC, 2012). While HPV is most often transmitted through vaginal or anal intercourse, it also is transmitted by skin-to-skin contact therefore condoms do not offer complete protection from the infection (Association of Reproductive Health Professionals, 2009). Like all viral infections, there is no cure for HPV the most infections usually resolve without any intervention (American Society for Colposcopy and Cervical Pathology, 2012).

Nearly 100% of cervical cancer cases test positive for HPV (Saslow et al., 2012). Additionally, there is a strong association between HPV and cancers of the vagina, penis, vulva, anus, and oropharynx (Association of Reproductive Health Professionals, 2009).

HPV 16 accounts for 55–60% of all cervical cancers, HPV 18 for an additional 10–15% cases, and 10 other HPV genotypes make up the remaining 25-35% of cervical cancer diagnoses (Saslow et al., 2012). It should be noted that types 6 and 11 are associated with condylomata acuminata, or external genital warts, but not cervical cancer (Association of Reproductive Health Professionals, 2009). HPV types 16 and 18 are considered high-risk due to their relationship to cervical cancer. In 2012, an estimated 12,170 cases of invasive cervical cancer were diagnosed and 4,220 women died of the disease (Saslow et al., 2012).

The major contributing factor to cervical cancer is inadequate or lack of screening (Saslow et al., 2012). Among those who are rarely or never screened in the U.S. are racial and ethnic minorities, lower socioeconomic status, being foreign-born and living in the U.S. for less than 10 years, and lack of access to health care and health care payment coverage (Saslow et al., 2012).

Although cervical cancer is now the 14th leading cause of cancer death in the United States, just 50 years ago it was the most frequent cause of cancer

death in women (Saslow et al., 2012) and continues to be the second most common cancer in women worldwide (World Health Organization, 2010). Increased cervical cancer screenings with Papanicoulaou smears¬—commonly referred to as Pap testing— and technological improvements in screening methods have significantly reduced cervical cancer mortality (Saslow et al., 2012). In recent years, two HPV vaccines have been introduced. Released in 2006, Gardasil offers protection from HPV types 6, 11, 16 and 18 in females aged 9 to 26 and genital warts caused by types 6 and 11 in males aged 9 to 26 (Food and Drug Administration [FDA], 2011). Cervarix was released in 2009 and offers protection from HPV types 16 and 18 in females between the ages of 9 and 25 (FDA, 2011). Vaccination does not preclude the need for screening (Association of Reproductive Health Professionals, 2009).

HPV and cervical cancer are terms often used interchangeably and the general health care practitioner as well as clients may have difficulty distinguishing between various types of abnormal Pap smear results and cervical cancers. It is crucial that health care providers understand the differences and be able to clearly articulate them to clients. Cervical dysplasias as detected by cytology are as follows: • Atypical squamous cells (ASC): This means that detected squamous cells do not appear normal but are not quite abnormal either. It includes two subcategories of ASC of undetermined significance (ASC-US) and ASC-cannot rule out highgrade (ASC-H). 50%-60% of women who receive this result are HPV negative and have no cervical pathology. ASC-H is a rarer finding, however, 60%-80% of women who receive this finding test positive for high-risk HPV types and the risk for more advanced cervical cancer is much higher than with ASC-US. • Atypical glandular cells (AGC): This is a rare Pap smear finding that means detected glandular cells do not look either normal or abnormal.

This finding has a greater risk of squamous and glandular precancer or cancer than any Pap smear finding except for high-grade squamous intraepithelial lesion (HSIL), which will be further discussed below.

• Low-grade squamous intraepithelial lesion (LSIL): In women under the age of 35, 83%-94% also test positive for HPV. 50% of women over

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the age of 35 with LSIL will test positive for HPV, which suggests that the cervical changes in the other 50% are unrelated to HPV and may be due to hormonal changes due to aging. Across all age groups, 70% of women with LSIL will have vaginal or cervical cell changes due to HPV, though most of the changes are low-grade.

• High-grade squamous intraepithelial lesion (HSIL): Over 90% of women with HSIL will have cell changes due to high-risk HPV types. Cervical changes are often high-grade with this Pap smear interpretation.

• Cancer: Very rarely, a Pap smear can be suspicious for cancer.

(American Society for Colposcopy and Cervical Pathology, 2012) The following are histological categories of cervical dysplasia, or cervical intraepithelial neoplasia (CIN): • CIN I: mild dysplasia • CIN II: moderate dysplasia confined to the basal 2/3 epithelium • CIN III: Severe dysplasia that covers more than 2/3 of the epithelium and may involve full thickness. Also includes carcinoma in situ.

(MedlinePlus Medical Encyclopedia, 2012)

Most HPV infections are asymptomatic and become undetectable upon screening and testing within one to two years of initial diagnosis (Saslow et al., 2012). Current screening guidelines in the United States recommend that women begin cervical cancer screening with Pap tests at 21 years of age (Saslow et al., 2012). For women under the age of 30, annual screening leads to twice the number of colposcopies performed and offers no significant reduction in cancer incidence, therefore it is generally recommended that women be screened every three years (Saslow et al., 2012). For women between the ages of 30–64, cytology and HPV testing every five years is recommended (Saslow et al., 2012). Current guidelines recommend that screening be stopped at age 65 for women with adequate negative screening (defined as three consecutive negative Pap smears or two consecutive negative HPV tests) and no diagnosis of CIN2 or greater in the last 20 years (Saslow et al., 2012). Current studies on the effectiveness of testing for HPV in males are ongoing (Association of Reproductive Health Professionals, 2009)

Given HPV’s transient nature, lack of sympVol 6, Iss 1, 2012-2013

toms and cure, and link to cancer, it is understandable that many patients and clients find screening and follow-up distressing. The anxiety present may impede initial screening and recommended follow-up. The fact that the infection can remain undetected and latent for years may increase uncertainty and anxiety (Rosen et al., 2010). Additionally, because HPV follow-up can take years for some clients, it is crucial that nurses and other health care providers attune themselves to their clients’ psychosocial and informational needs by offering accurate information and, just as importantly, perspective.

Presentation of Empirical Evidence How Demographics Impacts Information Dissemination

Although simulated laboratory experiments have found that people prefer to have information prior to a potentially stressful event, studies in nonlaboratory settings that more closely reflect authentic clinical environments have found that people actually prefer to distract themselves from distressing events (Miller & Mangan, 1983). Additionally, one landmark study on the effect of informational leaflets on psychosocial responses to colposcopy found that patients who received limited information about the procedure experience less discomfort than those who received high levels of information about the procedure (Miller & Mangan, 1983). On the opposite end of the spectrum, when clients perceive the information given by their health provider as inadequate, this also increases anxiety scores (de Bie et al., 2011).

Informational leaflets regarding HPV can be classified into two main groups: those that encourage screening for HPV and cervical cancer and those that provide information on the medical implications of an abnormal Pap smear result (Hall et al., 2008). Materials that encourage screening often used alarmist language, such as “Don’t delay—it could save your life!”, which belies the fact that most HPV cases do not progress to cervical cancer (Hall et al., 2008) and can potentially increase anxiety in the reader. Conversely, brochures geared towards women who have already received abnormal screening results used calm, reassuring language and contained more information about the sequelae of HPV (Hall et al., 2008).

Creators of health-related information pamphlets often target each document to certain demographic groups. While the intention behind tailoring health information materials is inclusion, the outcome may be less than desired. In HPV leaflets targeted to

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lesbian women, sexual practices were covered more frequently than in pamphlets directed at other groups (Hall et al.,, 2008). In HPV booklets directed towards older women, sexuality was discussed only within the context of heteronormative, monogamous marriage while materials directed towards women with disabilities ignored the issue of sexuality entirely (Hall et al., 2008). The assumptions made about each group determined the depth of information given and may have hindered the full dissemination of accurate HPV information.

HPV brochures and web sites have been inclusive of men but information specifically regarding cervical cancer is still mostly directed towards women (Hall et al. 2008). Additionally, cervical cancer information may not focus as much on transmission and strategies for disclosing to partners, which may add to the sense of stigma and isolation the female client may already feel (Hall et al., 2008).

How Information is Integrated into the Patient’s Experience

Even when information is presented with clinical accuracy, ensuring that the client’s personal view of their illness matches this is a challenge. The Common Sense Model of Illness Representation (CSM) states that people identify with an illness in five domains: identity (signs and symptoms of an illness), perceived cause, timeline (how an illness unfolds over time), controllability (prevention and treatment of an illness), and consequences (Marlow, Wardle, Grant, & Waller, 2009). Additionally, even when people are not personally diagnosed with an illness, they will conceptualize any illness using these five domains (Marlow et al., 2009). An additional feature of CSM is that an illness is experienced cognitively through facts as well as emotionally, culturally, and socially (Diefenbach & Leventhal, 1996). The pathophysiology of an illness is just one of many pieces of information that needs to be conveyed to patients and clients in order to encourage them to seek care and it may not even be the most compelling one (Diefenbach & Leventhal, 1996). If information provided in the clinical setting is not modified to address these complex needs, effective numbers of clients may not seek care.

Potentially Effective Interventions in Reducing the Psychososial Burden of HPV

Despite the outlined problems with informational materials, it is unlikely that they will be replaced. Written materials in clinical settings are ubiquitous, cost-effective, and they allow clients to Vol 6, Iss 1, 2012-2013

have clinical information to refer to on their own time.

The most potent way to strengthen the impact of information dissemination in the clinical environment is to combine it with individual counseling. Face-to-face or phone interaction with a nurse has been shown to improve follow-up rates when compared to only distributing pamphlets or letters (Mitchell & Hall, 2009).

Additionally, no pamphlet can replace the role of patient education. Nurses and other clinicians should spend ample time with patients clarifying the course of HPV and explaining the difference between high-risk and low-risk types of the infection (Perrin et al., 2006). It also is crucial for nurses and other health care providers to recognize that, although providing more information may increase client knowledge about HPV, this does not correlate with decreased anxiety (de Bie et al., 2011). It is imperative for clinicians to provide emotional support to their clients or be prepared to refer them for more extensive aftercare as needed (Bertram & Magnussen, 2008). The relationship between the clinician and the client has a greater impact on reducing anxiety than does providing information alone (de Bie et al., 2011). Patients themselves reported that face-to-face support from health care providers, rather than mailed notification of test results, and more time to talk during office visits were most effective in reducing anxiety (Neill & Waldrop, 1998).

A Cochrane review of interventions to reduce anxiety in clients undergoing colposcopy only found sufficient evidence for playing music during colposcopy to reduce pain and anxiety (Galaal, Bryant, Deane, Al-Khaduri, & Lopes, 2011). There was insufficient evidence to either support or negate the use of counseling; video colposcopy; information using graphs, verbal information, or video; or information brochures used in conjunction with informational videos to reduce anxiety (Galaal et al., 2011). Although the review could not find supporting evidence for information brochures to reduce anxiety, the review did find that this intervention is important for informed consent and in reducing psychosexual dysfunction (Galaal et al., 2011).

Overall, the evidence has not uncovered one intervention that can completely eliminate anxiety. It may not be desirable to reduce anxiety as that response may actually drive clients to continue following-up with their health care provider (de Bie et al., 2011).

Furthermore, it is understandable that a client will experience emotional discomfort when faced with a

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change in health status. It is more prudent for clinicians to focus on reducing excessive anxiety rather than seeking to eliminate it entirely and assessing the client’s needs in order to keep them in the system for follow-up (de Bie et al., 2011) .

Assessment of the State of the Science of the Empirical Evidence

Because this inquiry sought to understand the complex mechanisms behind people’s psychosocial responses, qualitative research designs were the most appropriate studies to utilize. A total of 14 studies were reviewed. Seven were qualitative studies, five were randomized controlled trials (RCTs), and the remaining two were quasi-experimental studies. The qualitative studies focused on the phenomenological experiences of study participants while the RCTs examined quantifiable impacts of various informational interventions (for example, using reliable tools to measure anxiety). The remaining documents were clinical practice guidelines or consensus recommendations.

The limitations of most of the qualitative studies are their small sample sizes, lack of generalizability to a larger population because of their focus on unique phenomena, and a lack of diversity within the samples (many of subjects were white, educated, middle-class, heterosexual, English-speakers, and partnered). Additionally, seven of the studies took place in the United Kingdom and Australia rather than the United States. For example, in a qualitative study

by Mitchell and Hall (2009), the sample size was eight and included seven self-identified heterosexual women, six white women and no Latina or AfricanAmerican participants, four were college-educated, and three self-identified as monogamous and partnered (married and unmarried) women (Mitchell & Hall, 2009). Furthermore, the age range was 18-62 with a median age of 31 (Mitchell & Hall, 2009). Such demographic homogeneity leaves out black and Latina women as well as newly immigrated women, all of whom are at higher risk for inadequate or no cervical cancer screening and therefore are at greater risk for cervical cancer mortality and morbidity (Saslow et al., 2012). Furthermore, many of the structured interviews in these studies were conducted by health care providers, which may have influenced the respondents’ comments.

The greatest strength of the included qualitative studies is the use of phenomenology as a research method. This technique provides unique, descriptive information that can capture the essence of emotional Vol 6, Iss 1, 2012-2013

experiences and guide the formation of future qualitative and quantitative studies. In a study by Bertram and Magnussen (2008), 30- to 60-minute interviews were taped verbatim and analyzed. They uncovered that participants identified individualized information and supportive counseling resources as the most powerful interventions (Bertram & Magnussen, 2008).

The strengths of the RCTs include larger sample sizes and the use of previously validated tools, such as the State-Trait Anxiety Inventory to measure anxiety levels (Kola & Walsh, 2011).

Although the sample sizes in the qualitative research studies were small, this is a common feature of this type of research. The quality of these studies, however, is high because the methods used for data collection were adequately described and limitations were clearly defined (Jones, 2010). For the RCTs included, the sample sizes were based on power analysis and research subjects were analyzed in the groups in which they were randomized to (Jones, 2010). Overall, the evidence consistently shows that, while informational interventions may not always reduce or alleviate anxiety in HPV-positive clients, combining information with a face-to-face interaction between the health care provider and the client may have a great impact on alleviating emotional distress.

The biggest gap in knowledge is the impact of online HPV information on anxiety and knowledge. There is a paucity of research regarding how this information is utilized by clients and if clinicians have enough knowledge about these resources to recommend them to clients. Bertram and Magnussen (2009) uncovered that participants viewed information obtained from the internet as private and allowed for more time to reflect on the information. But if the HPV information was derived from a general website about sexually transmitted infections, it was viewed as confusing and stigmatizing (Bertram & Magnussen, 2009).

Recommendations Implications for Practice

Although further research needs to be conducted on tailoring informational interventions and testing the utility of other interventions in reducing anxiety in HPV-positive clients, there is enough evidence to urge a change in practice. Namely, more personalized care needs to be offered to clients facing an HPV diagnosis so that they navigate the complexity of the infection and stay in the layered screening and treatment process long enough for it to be effective.

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Implications for Education

In order to enact these changes, nurses and other health care providers need training during their initial education and throughout their practice on how to best counsel HPV-positive patients and assess the value of the information they disseminate. Nurses also can take on a leadership role by utilizing their increased knowledge by creating evidence-based informational brochures.

Implications for Policy

More staff may be needed in order to meet the demand of providing individualized counseling. Personalized interventions may be more costly initially but they may be more beneficial in the long-run if they increase the number of clients who are adherent to recommended management guidelines. Furthermore, some anxiety-reducing interventions, such as playing music during colposcopy, are cost-effective and relatively simple to implement.

Implications for Research

Although this paper focuses on written materials distributed in the clinical setting, further research needs to be conducted on the accuracy and impact of online resources. Additionally, more RCTs are needed on the impact of various psychosocial interventions.

Finally, the qualitative and quantitative research studies conducted in this field needs to recruit more diverse populations since the populations at greatest risk for cervical cancer morbidity and mortality are sorely underrepresented in the research.

References American Society for Colposcopy and Cervical Pa thology. (2012). Diagnosis of HPV-induced disease. Retrieved on December 5, 2012 from http://www.asccp.org/PracticeManagement/ HPV/DiagnosisofHPVInducedDisease/tabid/ 5825/Default.aspx#screening American Society for Colposcopy and Cervical Pathology, 2012 Association of Reproductive Health Professionals.

(2009). Managing HPV: A new era in patient care.

Bertram, C. C., & Magnussen, L. (2008). Informational needs and the experiences of women with abnormal Papanicolaou smears. Journal of the American Academy of Nurse Practitioners, 20(9), 455–462. doi:10.1111/j.1745-7599.2008.00341.x Centers for Disease Control and Prevention. (2012).

Genital HPV infection—fact sheet. Retriev ed Vol 6, Iss 1, 2012-2013

December 5, 2012 from http://www.cdc.gov/ std/HPV/STDFact-HPV.htm Daley, E.M., Perrin, K.M., McDermott, R.J., Vamos, C.A., Rayko, H.L., Packing-Ebuen, J.L., …McFarlane, M. (2010). The psychosocial burden of HPV: A mixed-method study of knowledge, at titudes, and behaviors among HPV+ women.

Journal of Health Psychology, 15(2), 279–290, doi:10.1177/1359105309351249 Diefenbach, M.A., & Leventhal, H. (1996). The common-sense model of illness representation: Theoretical and practical considerations.

Journal of Social Distress and the Homeless.

5(1), 11–38. de Bie, R.P., Massuger, L.F., Lenselink, C. H., Derk sen, Y.H.M., Prins, J.B., & Bekkers, R. L. (2011). The role of individually targeted information to reduce anxiety before colposcopy: A randomised controlled trial. BJOG : An International Journal of Obstetrics and Gynaecology, 118(8), 945–950. doi:10.1111/j.14710528.2011.02996.x; 10.1111/j.1471-0528.2011.02996.x Food and Drug Administration. (2010. Approved products: Cervarix. Retrieved from December 5, 2012 from http://www.fda.gov/BiologicsBlood Vaccines/ Vaccines/ApprovedProducts/ucm186957.htm Food and Drug Administration. (2010. Approved prod ucts: Gardasil. Retrieved from December 5, 2012 from http://www.fda.gov/BiologicsBloodVaccines/ Vaccines/ApprovedProducts/UCM0940.htm Galaal, K., Bryant, A., Deane, K. H., Al-Khaduri, M., & Lopes, A. D. (2011). Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database of Systematic Reviews (On line), (12)(12), CD006013. doi:10.1002/14651858.

CD006013.pub3 Hall, B., Howard, K., & McCaffery. (2008). Do cervical cancer screening patient information leaflets meet the HPV information needs of women? Pa tient Education and Counseling, 72, 78–87.

Howells, R.E., Dunn, P.D., Isasi, T., Chenoy, R., Cal vert, E., Jones, P.W., . . . Redman, C.W.E. (1999).

Is the provision of information leaflets before col poscopy beneficial? A prospective randomised study. British Journal of Obstetrics & Gynaecology, 106(6), 528–534.

Johnson, C.Y., Sharp, L., Cotton, S.C., Harris, C.A., Gray, N.M., Little, J., & TOMBOLA Group.(2011).

Human papillomavirus infection and anxiety:Analyses in women with low-grade cervical cytologi

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9

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Psychology & Health, 25(6), 651–668 doi:10.1080/ cal abnormalities unaware of their infection status.

08870440902822913 PloS One, 6(6), e21046. doi:10.1371/journal.

Saslow, D., Solomon, D., Lawson, H. W., Killackey, pone.0021046 M., Kulasingam, S. L., Cain, J.,... Myers, E.R. Jones, K.R. (2010). Rating the level, quality, and (2012). American Cancer Society, American Soci strength of the research evidence. Journal of Nursety for Colposcopy and Cervical Pathology, and ing Care Quality, 25(4), 304–312.

American Society for Clinical Pathology Screen Kola, S., & Walsh, J. C. (2012). Determinants of ing guidelines for the prevention and early detec pre-procedural state anxiety and negative affect in tion of cervical cancer. American Journal of Clini first-time colposcopy patients: Implications for Intcal Pathology, 137(4), 516–542. doi:10.1309/AJervention. European Journal of Cancer Care, 21(4), CPTGD94EVRSJCG 469–476. doi:10.1111/j.13652354.2011.01317.x World Health Organization. (2010). Human papil Maggino, T., Casadei, D., Panontin, E., Fadda, E., lomavirus (HPV). Retrieved on December 5, 2012 Zampieri, M.C., Donà, M.A., . . . Altoe, G. (2007). from http://www.who.int/immunization/topics/hpv/ Impact of an HPV diagnosis on the quality of life in en/ young women. Gynecologic Oncology, 107(1 Supp1), S175–S179. doi:10.1016/j.ygyno.2007.07.013 Marlow, L.A.V., Wardle, J., Grant, N., & Waller, J. (2009). Human papillomavirus (HPV) information needs: A theoretical framework. Journal of Family Planning and Reproductive Health Care, 35(1), 29–33. doi:10.1783/147118909787072432 Medline Plus. (2012). Cervical dysplasia. Retrieved on December 5, 2012 from http://www.nlm.nih.gov/ medlineplus/ency/article/001491.htm Miller, S.M., & Mangan, C.E. (1983). Interacting effects of information and coping style in adapting to gynecologic stress: Should the doctor tell all? Journal of Personality and Social Psychology, 45(1), 223–236.

Mitchell, S., & Hall, V. P. (2009). Women’s initial ex perience of abnormal Papanicolaou smear. Journal of Holistic Nursing: Official Journal of the Ameri can Holistic Nurses’ Association, 27(2), 93–102. doi:10.1177/0898010108330806 Neill, E.H., & Waldrop, J.B. (1998). Changes in body image, depression, and anxiety levels among women with human papillomavirus infection. Journal of the American Academy of Nurse Practitioners, 10(5), 197–201.

Perrin, K., Daley, E.,M., Naoom, S.,F., PackingEbuen, J.,L., Rayko, H.,L., McFarlane, M., & McDermott, R.,J. (2006). Women’s reactions to HPV diagnosis: Insights from in-depth interviews.

Women & Health, 43(2), 93–110. doi: 10.1300/ J013v43n02¬06 Rosen, N. O., Knäuper, B., Di Dio, P., Morrison,E., Tabing, R., Feldstain, A.,... Rosberger, Z. (2010).

The impact of intolerance of uncertainty on anx iety after receiving an informational intervention about HPV: A randomised controlled study.

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The Implications of Change on Advanced Practice Psychiatric-Mental Health Nursing Scott C. Schmidt, BA, BSN, RN Abstract Discussions regarding the certification of the psychiatric-mental health (PMH) clinical nurse specialist (CNS) resulted in its elimination by the American Nurses Credentialing Center (ANCC), effective 2014. The sole remaining advanced practice registered nurse (APRN) certification for providing psychiatric and mental health care will be the Family Psychiatric Nurse Practitioner (NP). Disagreement still lingers with the changes in certification, including fears that the role of the PMH-CNS, which include care for the child and adolescent patient population and psychotherapy, will no longer exist. Additional concerns include the loss of duties traditionally performed by PMH-CNS to other behavioral health disciplines. In contrast to these fears are the hopes that a single title will reduce confusion among consumers and professionals, allow for an improvement in the allocation of resources for roles with similar core functions, and better address the current needs of individuals seeking mental health care. This paper describes the implications of such a transition and how even with a change in title, the role of the CNS can and should survive.

Implications of Change on Advanced Practice Psychiatric-Mental Health Nursing

The history of the psychiatric-mental health clinical nurse specialist is impressive. As one of the initial advanced practice roles in nursing (Harahan, Delaney, & Stuart, 2012), the PMH-CNS has evolved into an autonomous yet dynamic leadership role in the behavioral health workforce. Today, PMH-CNSs are viewed as graduate-prepared APRNs who utilize biological, social, and psychological models and “a variety of theoretical frameworks to facilitate the understanding of individuals, groups and systems; and a variety of individual and group psychotherapeutic treatment modalities to support comprehensive treatment and consultation” (Dempsy & Ribak, 2012, p.

296). Their expertise may be observed in multifarious settings including hospitals, outpatient clinics, along with an array of organizations and institutions (Jones & Minarik, 2012). Ironically, as of the year 2014 (Jones & Minarik, 2012) the PMH-CNS—one of the pioneers for advanced practice nursing—will no longer have an examination offered by the American Nurses Credentialing Center (ANCC), the impacts of which will end the credentialing for the PMH-CNS.

The aforementioned announcement by the ANCC encountered oppositional voices within the APRN-PMH community. Nevertheless, the recommendations formulated by the joint International Society of Psychiatric Mental Health Nurses/American Psychiatric Nurses Society (ISPN/APNA) Task Force of the implementation of licensure, accreditation, creVol 6, Iss 1, 2012-2013

dentialing, and education (LACE) contributed to the transition toward a Consensus Model for Advanced Practice (Regan-Kubinski & Horton-Deutsch, 2012).

In 2014 their will be a termination of the PMH-CNS credentialing, as well as the elimination of the Adult Psychiatric and Mental Health Nurse Practitioner examination, and that those choosing to practice as an advanced practice psychiatric nurse will have only one option—the Family Psychiatric Nurse Practitioner (across the lifespan) certification (Jones & Minarik, 2012). Although this decision has led to uncertainty amongst the APRN-PMH contingent, the change has the potential to improve the strength and unity of the psychiatric-mental health nursing profession.

Positive appraisal of the transition in psychiatric-mental health advanced practice nursing should not be interpreted as a promotion of the PMH-NP as a replacement for the PMH-CNS due to a lack of capability. Rather the position is that it affords the profession the opportunity to consolidate the roles into a singular title. This concept is not novel, as hybrid programs have existed for years, although these programs are without consensus as to what educational training and preparation is necessary (Jones & Minarik, 2012).

The transition toward the integration of competencies will require both the collaboration and cooperation of all parties involved with LACE.

There are other practical considerations, which must be addressed to ensure the viability of the APRN-PMH practice. So long as the debate over role and titling demonstrates reluctance toward resolution,

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others that provide care for those with behavioral health problems will continue to encroach upon roles that may be provided for by the body of APRNPMHs. Moreover, professionals outside of those who traditionally provide care for patients with behavioral health problems, including APRNs in different specialties such as family nurse practitioners, will increasingly treat these patients while the professional boundaries of APRN-PMHs remain clouded (McCabe & Grover, 1999).

As previously discussed, the transition to one title for APRN-PMHs is not an issue of which has more value, but rather one rooted in pragmatic substance. Therefore, with an understanding of the roles, functions, and knowledge of the CNS, this paper will discuss which of these are and are not currently being absorbed into the PMH-NP role, their future potential to be absorbed, and to evaluate the consequences and implications for care, policy, education, and research.

Method

A literature review was conducted to discover research articles describing the current advanced practice psychiatric-mental health workforce. Four online databases were utilized during this search, including Cumulative Index of Nursing and the Allied Health (CINAHL), Medline (PubMed), PsychINFO, and MEDLINEPlus/OVID. Variability between database searches existed due to differences in features specific to each database.

A Medline search was conducted using the terms psychiatric nursing, advanced nursing practice, and workforce, and resulted in 27 articles. These returned results were narrowed to 10 articles after applying parameters that limited the results to include only articles written in the English language from 2007 to 2012. Among these results, two were eliminated because they were commentary on other articles.

Another article was eliminated because it was a qualitative study on the experience of nursing students, and was irrelevant to the focus of this paper. This same search process was utilized in PsycINFO, CINHAL, and MEDLINEPlus/OVID using the search parameters as previously described. These results returned an additional 22 articles (6 from MEDLINEPlus/OVID, 9 from PsychINFO, and 7 from CINAHL). Duplicate articles that were returned from the various databases were eliminated along with articles that did not fit the scope of this paper, including articles describing the advanced practice psychiatric-mental health nursing workforce outside the United States. Five additional Vol 6, Iss 1, 2012-2013

articles were included after a review of the reference lists of the articles initially discovered in the database search. These articles were topically relevant but were outside the initial search parameters, which ranged from the years 1995 to 2003. A total of 17 articles were used for the review and synthesis of the current advanced practice psychiatric-mental health nursing workforce. These articles discuss the implication for the changing titles, certifications, and education, as well as the impact each of these items may have on the role of the APRN-PMH. Lastly, a broad range of sources such as databases, conference proceedings, and government and national nursing association data were comprehensively evaluated to provide background for this paper.

Results Examining the evidence

Knowing that the transition away from the titling and certification of the PMH-CNS is inevitable, much of the literature focuses on the future by drawing upon conclusions from the past and current state of the profession. The literature attempts to demonstrate what roles and knowledge bases may survive, what may be lost, and the reasons for such.

The debate over the differences of roles, responsibilities, and educational preparation between psychiatric mental health clinical nurse specialists and psychiatric mental health nurse practitioners is certainly not new. In a 1999 article by McCabe & Grover entitled Psychiatric nurse practitioner versus clinical nurse specialist: Moving from debate to action on the future of advanced psychiatric nursing, the authors concluded that incorporating the roles of both PMH-CNS and the PMH-NP was necessary. This idea of a blended approach is observed throughout the literature, although it is the implementation of such an approach that poses substantial challenges.

Some of these challenges include incorporating the competencies of the PMH-CNS and the PMH-NP that do not overlap into the educational preparation of a blended program. Of course, the larger the overlap, the less challenging it should be to combine the two roles. A job analysis performed by a task force assembled by the American Psychiatric Nursing Association found a commonality of 90% between the practices of PMH-CNSs and PMH-NPs (Rice, Moller, DePascale, & Skinner, 2007). For those that promote integrating competencies, this is an encouraging finding. Nevertheless, for those that fear losing the essential roles of the PMH-CNS, these results may suggest that there is

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not a major difference in roles between PMH-CNSs and PMH-NPs. Thus, the rationale for the concern for losing the traditional roles of the PMH-CNS may be unfounded.

A real challenge for maintaining the traditional roles of the PMH-CNS, such as the usage of psychotherapy in practice, has more to do with the changing reimbursement climate than it does with the PMHCNS being overtaken by PMH-NP competencies.

After all, it was just shown that evidence exists for the similarity among competencies between the two.

What does appear to be true is that the reduction in reimbursement for services means that it is less economically viable to perform these services. Theoretically, there is an amount of money a payer may reimburse that transforms a profession into charity. For example, Delaney and Handrup explained that although many APRN-PMHs find psychotherapy to be “an essential element of their work,” (p. 303), the reimbursement for medication therapy and assessment is superior to that of psychotherapy (2011). This phenomenon of shifting away from certain competencies valued by PMH-CNS and other behavioral health professionals alike may also reflect the needs of the current population.

There is a current demand for licensed providers capable of providing comprehensive care across the lifespan (Delaney, 2009). Of the four existing APRN-PMH certifications—Child and Adolescent CNS, Adult CNS, Adult NP, and Family NP—only one facilitates the educational preparation to provide such care. Furthermore, the inadequate number of professionals licensed to prescribe medication increases the desirability of PMH-NPs and their educational preparation having a focus on psychopharmacology.

This need becomes increasingly important due to the shortage of psychiatrists in the United States. Moreover, the evolving nature of the behavioral health care industry favors a model that emphasizes medications and psychopharmacology (Delaney, Hamera, & Drew, 2009). A need for prescribers of medications will exist, and the preparation of the PMH-NP is one solution to address this shortage. Furthermore, the need for access to behavioral health providers that prescribe (96% of counties in the United States underserved) significantly outweighs the behavioral health need of providers that do not prescribe (18% of counties in the United States underserved) (Hanrahan et al., 2012).

This data must not be interpreted as a difference in importance or effectiveness of providers, but rather a Vol 6, Iss 1, 2012-2013

difference in need. Consequentially, with a demand for those that can prescribe (Kaas et al., 2000), it is not a coincidence that graduates from APRN-PMH programs have responded to this demand by requesting more training in prescribing. Delaney, et al., used a descriptive survey of APRN-PMHs and found that there was an overall desire to have more instructional content on psychopharmacology and the practice of prescribing (2009).

Another factor implicated in the abolishment of the PMH-CNS position is a history of producing little data on patient outcomes (Hanrahan et al., 2003).

It is not that the ending of certification of PMH-CNSs is a result of poor-quality, inadequate to that of PMHNP, but rather a product of misfortune in the context of the demands of the political environment. Though outcomes data do exist, such as Baradell, J. G. (1995), the rate and consistency at which the outcomes data emerges remains insufficient. While positive outcomes and patient satisfaction appear in the literature (Baradell & Bordeaux, 2001), the scarcity of research in this area may suggest a lack of evidenced-based practices often required for reimbursement for services provided.

Discussion State of the Science

Synthesizing the empirical findings of multiple studies each evaluating unique variables presents a challenge when appraising the state of the science.

Nevertheless, the studies that do exist are rarely empirical in nature, and often synthesis articles themselves. However, when assessing the literature used for this paper, the quality of evidence is good (B) to high (A), whereas the strength of the evidence ranges from level V to level III. The data is rather consistent in that, when taken as a whole, the research designs are appropriate in the context of attempting to predict the future; this requires the utilization of measurement, empiricism, and expert-understanding of the past to formulate such future predictions (Polit & Beck, 2008).

Such research was consistently performed by expert opinions of nationally recognized panels and consensus panels with clearly evident expertise (level IV-A evidence). Furthermore, much of the literature utilized for this paper included the opinions of individual experts based on literature review, organizational experience, and personal expertise (level V-A evidence). Although the quality of the evidence remains high, the strength of the evidence could improve, but

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again is limited by the nature of the question this paper attempts to address.

In regards to the non-experimental studies used in this paper, not one had a level of evidence greater than level III-B. Specifically, there could be more extensive research into the differences between the roles of the PMH-CNS and the PMH-NP, as only one study showed the limited differences in roles (Rice et al., 2007). Expert opinion also questions the validity of the results of this study, specifically citing the lack of inclusion of roles pertaining to the common practice of PMH-CNSs:

The results reflect the bias inherent in the questions. The majority of the questions were in the client domain, therefore providing limited information about the totality of PMH-CNS practice. In addition, questions about non-pharmacological functions that impact care quality, that is, organizational consultation, the system as client, research, and consulting with nursing personnel, were shallow and did not capture the depth and breadth of skills needed. A study that concludes “no difference” in practice between the psychiatric CNS and NP practice most likely reflects the failure to ask a full range of questions about the practice of CNSs. (Jones & Minarik, 2012, p. 123)

Although the knowledge surrounding the implications of the evolving nature of the APRN-PMH, through improving our understanding of the differences (or lack thereof) among how PMH-CNS and PMH-NP practice, better methods of combining the identified variable roles may be actualized.

Recommendations

There is an opportunity during this time of transition among the APRN-PMH field, for the newlylabeled family psychiatric-mental health nurse practitioner to address many of the challenges that previously were not possible. This shift in the field has significant implications for practice, policy, education and research, which will be discussed in the subsequent paragraphs.

The transition from an APRN system that had two providers that perform similar care to a unified provider that integrates the roles of both the PMHCNS and the PMH-NP may have the largest impact on practice. Full-spectrum healthcare is limited to psychiatrists, APRN-PMHs, and psychologists in 2 states (Hanrahan et al, 2012). After expanding their certification to allow all APRN-PHMs to provide care for individuals across the lifespan, APRN-PMHs would be in a better position to provide such full-spectrum Vol 6, Iss 1, 2012-2013

care. The ability to serve the lifespan may address the chronically underserved child and adolescent population, where all APRN-PMHs certified after 2014 will be able to provide care for this demographic, whereas only a fraction of APRN-PMHs can currently treat this population.

Through the combination of the APRN-PMH workforce into one solitary unit, the capability of producing research increases within the field. The existence of both the PMH-CNS and PMH-NP currently allows for the potential duplication of outcomes research under separate titles. The distinctive qualities between the two are outweighed by their similarities, and the overall production of research from APRNPMH becomes confusing and diluted, not only to those in the profession but also to policymakers. In regards to this disconnect “the assumption was that the underlying problem with CNS enrollments was a gapping public knowledge deficit” (Delaney, 2009, p. 454). The author continues to assert that not only could there be a problem with understanding the role of the PMH-CNS among policymakers and the public alike, but also that this disconnect may be due to the PMH-CNS tradition of providing therapy is outweighed in manpower, and thus the influence of policy, by other professionals (e.g. psychologists), 40to-1. By combining numbers and reducing confusion among the population, we can strengthen the impact of the research that is needed to guide policy.

It is essential that policymakers have an increased awareness of the capabilities of the APRNPMH workforce, and therefore there is an important connection between research and policy. To this end, it is essential to produce outcomes research. This may include creating new ways to measure outcomes of those APRN-PMHs whose outcomes are difficult to measure when not working independently. Furthermore, policymakers may have limited funding to APRN-PMHs because the majority of them are CNSs, and often do not have roles in the provision of direct care (Hanrahan et al, 2010). By transitioning to one title, policymakers may be more likely to recognize the size and benefits of the workforce.

Of course, the true integration of the differing competencies of the PMH-CNS and the PMH-NP must happen at the educational level. This poses some significant challenges, as one study showed that an addition of 150 supervised clinical hours to the minimum 500 hours are needed to adequately prepare a student to have the comprehensive skillsets from the PMH-NP

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and PMH-CNS domains (Rice et al, 2007). Addressing increasing educational needs poses a challenging task, as there is already a well-known shortage of faculty and clinical sites; as faculty age and retire and clinical sites become increasingly crowded, it will be difficult to facilitate these increased needs. Furthermore, this will mean that the time of preparation will be longer, and this may deter students from pursuing an APRN-PMH license.

Conclusion

Continuing the debate regarding the variation among roles serves only to diminish the profession’s primary responsibility. PMH-CNSs and PMH-NPs must act with an approach that is less self-centered and more patient-centered. Though change often demands sacrifice, through working together to preserve and promote the core competencies that define not only psychiatric-mental health advanced practices nurses but also the entire nursing profession, patients will ultimately reap the benefits that nurses may offer. Although titles may be changing, it is up to the profession to ensure the services of all APRN-PMH backgrounds are maintained. And that is the message: A practice that changes in response to the needs of our patients does not mean that a practice is disappearing, yet evolving.

References Baradell, J. G. (1995). Clinical outcomes and satisfaction of patients of clinical nurse specialists in psychiatric-mental health nursing. Archives of Psychiatric Nursing, 9(5), 240-250. doi: 10.1016/ S0883-9417(95)80043-3 Baradell, J. G., & Bordeaux, B. R. (2001). Outcomes and satisfaction of patients of psychiatric clinical nurse specialists. Journal of the American Psychiatric Nurses Association, 7(3), 67-75. doi: 10.1067/mpn.2001.116045 Bjorklund, P. (2003). The certified psychiatric nurse practitioner: Advanced practice psychiatric nursing reclaimed. Archives of Psychiatric Nursing, 17(2), 77-87. doi: 10.1016/S08839417(03)00005-0 Delaney, K. R. (2009). Looking 10 years back and 5 years ahead: Framing the clinical nurse specialists debate for our students. Archives of Psychiatric Nursing, 23(6), 454-456. doi: 10.1016/j. apnu.2009.08.002 Delaney, K. R., Hamera, E., & Drew, B. L. (2009).

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advanced practice nursing: The adequacy of educational preparation: Voices of our graduates. Journal of the American Psychiatric Nurses Association, 15(6), 383-392. doi: 10.1177/1078390309353070 Delaney, K. R., & Handrup, C. T. (2011). Psychiatric mental health nursing’s psychotherapy role: Are we letting it slip away? Archives of Psychiatric Nursing, 25(4), 303-305. doi: 10.1016/j. apnu.2011.04.005 Dempsey, A., & Ribak, J. (2012). The future of the psychiatric mental health clinical nurse specialist: Evolution or extinction. Nursing Clinics of North America, 47(2), 295-304. doi: 10.1016/j. cnur.2012.02.003 Gordon, J. M., Lorilla, J. D., & Lehman, C. A. (2012).

The role of the clinical nurse specialist in the future of health care in the United States. Perioperative Nursing Clinics, 7(3), 343-353. doi: 10.1016/j.cpen.2012.06.006 Hanrahan, N. P., Delaney, K., & Merwin, E. (2010).

Health care reform and the federal transformation initiatives: capitalizing on the potential of advanced practice psychiatric nurses. Policy, Politics, & Nursing Practice, 11(3), 235-244.

Hanrahan, N. P., Delaney, K. R., & Stuart, G. W. (2012). Blueprint for development of the advanced practice psychiatric nurse workforce.

Nursing Outlook, 60(2), 91-104. doi: 10.1016/j. outlook.2011.04.007 Hanrahan, N., Stuart, G. W., Brown, P., Johnson, M., Draucker, C. B., & Delaney, K. (2003). The psychiatric-mental health nursing workforce: Large numbers, little data. Journal of the American Psychiatric Nurses Association, 9(4), 111-114. doi: 10.1016/S1078-3903(03)00156-3 Jones, J. S., & Minarik, P. A. (2012). The plight of the psychiatric clinical nurse specialist: The dismantling of the advanced practice nursing archetype.

Clinical Nurse Specialist, 26(3), 121-125. doi: 10.1097/NUR.0b013e318256855a Kaas, M. J., Dehn, D., Dahl, D., Frank, K., Markley, J., & Hebert, P. (2000). A view of prescriptive practice collaboration: Perspectives of psychiatric-mental health clinical nurse specialists and psychiatrists. Archives of Psychiatric Nursing, 14(5), 222-234. doi: 10.1053/apnu.2000.9813 McCabe, S., & Grover, S. (1999). Psychiatric nurse practitioner versus clinical nurse specialist: Moving from debate to action on the future of

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advanced psychiatric nursing. Archives of Psychiatric Nursing, 13(3), 111-116. doi: 10.1016/ S0883-9417(99)80041-7 Patten, S., & Goudreau, K. A. (2012). The bright future for clinical nurse specialist practice. Nursing Clinics of North America, 47(2), 193-203. doi: 10.1016/j.cnur.2012.02.009 Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Lippincott Williams & Wilkins.

Regan-Kubinski, M. J., & Horton-Deutsch, S. (2012).

Update on advanced practice RN regulation and its application to advanced practice psychiatric mental health nursing. Archives of Psychiatric Nursing, 26(1), 74-75. doi: 10.1016/j. apnu.2011.06.001 Rice, M. J., Moller, M. D., DePascale, C., & Skinner, L. (2007). APNA and ANCC collaboration: Achieving consensus of future credentialing for advanced practice psychiatric and mental health nursing. Journal of the American Psychiatric Nurses Association. 13(3), 153-159.

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The Birth of an Intersex Infant: Exploring the Options and Ethics Behind Decision-Making Dana Ovadia , BSN Abstract While joyous and miraculous, the birth of a healthy infant is an event laden with eustress, fear of inadequacies, and permutating visions of the future. Add to this the diagnosis of an intersex infant, and the family is catapulted into an abyss of unfamiliar questions and unexpected decision-making. Immediate surgical intervention to alter genitalia is a common decision, but is not the only option. An ethical debate stems around the core question of whether choosing the sex of a child is the responsibility of the parent, or of the child, as he or she ages. The psychological repercussions of sexual incongruencey resonates unabated throughout childhood and adolescence. The following paper explores the ethical considerations behind sex assignment surgery for intersex infants.

The Birth of an Intersex Infant: Exploring the Options and Ethics Behind DecisionMaking

In 2002, Pulitzer Prize-winning Jeffrey Eugenides, published the book, Middlesex, that chronicles the life of a child born with ambiguous genitalia.

While presence of ambiguous genitalia has been acknowledged since the late 14th century, this is one of the first novels that attempts to progress the discussion of ambiguous sexuality from a state of medical curiosity and societal stigmatism to one of open discussion and normalization.

In a field laden with power and rapid development, the four pillars of ethics have been constructed to guide medical professionals in making the most appropriate patient care decisions. In addition to the principles of nonmaleficence, beneficence, justice and autonomy, the American Nurses Association (ANA) has constructed nursing guidelines that help to unite the profession, identify shared values, delineate obligations and embody moral expectations (ANA, 2005).

The University of Pennsylvania’s Bioethicist, Connie Ulrich, PhD, defines an ethical issue as any situation that one believes has important moral challenges embedded within, that ultimately demands extrication and identification (Ulrich, 2009). An ethical issue is one that presents no obvious solution; one that may hold deep significance to those involved and unfortunately does not shout black or white. It is during these times of gray that nurses grapple for moral fortitude, employing the ethical guidelines prescribed to our profession, to seek and establish a solution that upholds these principles.

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One situation, fraught with ethical challenges, is the assignment of sex, and subsequent gender, in an intersex infant. The umbrella term intersex refers to “a group of disorders in which phenotype appearance of external genitalia does not occur in conformity with genotypic sex” (Akhtar, 2004). When an infant is born with gonad or sex discordance, it has been traditional in Western societies to choose a sex for the child and perform immediate surgery analogous to a potential medical emergency. In a culture restricted by a binary sex paradigm, it is not uncommon for both parents and healthcare providers believe it beneficial to assign a child a sex as soon as possible (Thyen, Richter-Appelt, Wiesermann, Holterhus & Hiort, 2005). Unfortunately, despite paucity in longitudinal research studies, results indicate many children are unsatisfied with their sex assignment.

“Whereas I, even now, persist in believing that these black marks on white paper bear the greatest significance, that if I keep writing I might be able to catch the rainbow of consciousness in a jar.” Jeffrey Eugenides, Middlesex

In a world of dual check boxes, sex and gender remain concepts easy to categorize into black and white.1 The truth remains that the complex interplay of chemistry, genetics, biology and environment, ensures a colorful spectrum of possibilities, not surprising in a world of cobalt blue and crimson. But what happens when a parent is handed a tightly bundled child, and told by their provider that they must choose whether they will be leaving the hospital with a Daniel

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or Danielle? Must they decide to cut, snip or sew?

Some experts claim that surgery is mutilating to an infant and not necessarily an appropriate reflection of what the child would want. The intersex dilemma materializes as a question emerges—if experts do not agree, how is a new parent, burdened with fear and uncertainty, expected to make such a life-altering decision? The following three articles address three of the most pivotal ethical concerns weighing upon the minds of the family of an intersex infant: Is corrective surgery the only valid option? Does a child have a right to choose? And lastly, what is the role of the health care team?

Is Corrective Surgery the Only Valid Option?

“I was born twice: first, as a baby girl, on a remarkably smogless Detroit day in January of 1960; and then again, as a teenage boy, in an emergency room near Petoskey, Michigan, in August of 1974.” Jeffrey Eugenides, Middlesex

A study conducted by Maharaj, Dhai, Wiersma and Moodley (2005), illuminates the trend for many health care providers formulate their gender reassignment recommendations based on the appearance of the external genitalia and the predicted outcome for the most successful surgery. The biological and psychological issues embedded within these individuals is still poorly understood and modern science has yet to validate whether sexual identity is determined by genes, society or culture (Maharaj et al., 2005). Surgery can, and often does, compromise sexual function but the absence of surgery can yield a confused youth inadequately prepared for adolescence. Assigning sex, however, does not guarantee that through puberty and adulthood the individual will conform to the gender identity assigned.

As an educator, the nurse’s role includes assisting parents to understand that immediate surgery is not the only option. Sex assignment surgery does not ensure a congruent identity across the lifespan, nor does an intersex infant necessitate emergent action.

Our technology is developing at a pace that supersedes our understanding of certain biological phenomena. In a culture accustomed to fixing problems, it might be helpful to reassure mothers that perhaps this is not a problem that requires immediate repair.

This article, by Maharaj et al. (2005), is unique, in that it is written by a team of physicians and lawyers, who explore the motivation behind this surgical trend.

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While they value science and technology, the authors unite in recommending a non-directional counseling approach that provides awareness of non-surgical management while encouraging psychological support for mother and child.

A Child’s Autonomy “But in the end it wasn’t up to me. The big things never are. Birth, I mean, and death. And love. And what love bequeaths to us before we’re born.”

Jeffrey Eugenides, Middlesex

Thyen et al. (2005) explore sex assignment by comparing the original “optimal gender policy” with the more progressive “full consent policy.” The original policy was designed utilizing the premise that “gender identity is predominantly determined by psychosocial influence, and accordingly that expedited gender assignment in the newborn period was warranted to avoid prolonged parental insecurity” (Thyen et al., 2005, p.3). The authors note that mothers harbor feelings of shame, guilt and secrecy when they receive their infant’s diagnosis, and underscore that the first policy was established to alleviate parental concerns.

The new policy suggests that genital operations in infants should only be carried out if malignancy is suspected. Otherwise the operations should only be performed under the child’s consent and that child has the right to choose his or her sex to match his or hers experienced gender.

The authors of this article honor the moral principle of autonomy, giving providers an opportunity to return some control to the child. By offering developmentally-appropriate information early, the nurse can help encourage the child to take an active role in questioning and decision-making (Thyen et al., 2005).

The nursing code of ethics states that the nurse’s primary responsibility is to the patient, whether an individual or family (ANA, 2005). As a nurse of the childbearing family, we embody a unique role, in that our patient is the family unit, encompassing infant and parents alike. The challenge formulizes as we make a suggestion that might create a divergence between the interest of parent and child. While immediate action might console a confused parent, the authors indicate the ethical option includes appreciating the voice of the child.

The authors acknowledge that very few studies have been dedicated to understanding the mental health of these individuals nor has patient satisfaction

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been used as an outcome. They boldly suggest that repeated medical examinations on the genitals can result in feelings of shame, fear, pain, and isolation, that mirror those feelings experienced by victims of sexual abuse. There is a need for future research to address how parents determines when their child is cognitively mature enough to make such a decision, and with whose help, as well as discuss whether healthcare providers, who support a child’s autonomy, are infringing upon the parent’s rights?

The Role of the Health Care Team “Plato said that the original human being was a hermaphrodite. Did you know that? The original person was two halves, one male, one female. Then these got separated. That’s why everybody’s always searching for their other half. Except for us. We’ve got both halves already.”

Jeffrey Eugenides, Middlesex

The third article is a composition piece of 50 international experts in the field, who congregated to review evidenced-based literature with the purpose of producing a consensus document. The authors attempt to tease apart the complex psychosocial aspects of sex and gender by distinguishing the differences among “gender identity,” “gender role,” and “sexual orientation.” They noted that although gender development initiates before age 3, it remains unclear at which age it can be accurately assessed. Additionally, the article details medical management, surgical outcomes, legal issues and role of the collaborative health care team (Lee et al., 2006).

In order to best advise and inform parents, the authors stress unified collaboration amongst the members of the healthcare team, despite knowing the best course of action might not be initially evident. They purport that an ideal multidisciplinary team should include endocrinologists, gynecologists, neonatologists, social workers, nurses, and a representative from medical ethics (Lee et al., 2006). Nurses can contribute to this team by offering developmentally appropriate education, disclosure, emotional support, empathy and cultural sensitivity to the family unit. Understanding the risk for psychological duress stemming from discrepancy between assigned sex and felt gender, as the child develops, the nurse should maintain a role as the child’s advocate, facilitating confidential conversations or family meetings (Lee, Houk, Ahmed, & Hughs, 2006).

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The article’s strength is the suggestion of a collaborative approach and a belief that ongoing education and action requires a flexible individual-based approach. The research highlights the fact that each case is unique and that tailored communication strategies should be initiated with the parents from the time of diagnosis (Lee et al., 2006). Surprisingly, the authors agree upon several actions that are morally equivalent, without exploring the controversial nature of the issue.

For example, they believe that all individuals should be assigned a sex (Lee et al., 2006), and relinquish any possibility that the child may choose for herself under the full consent policy. In a similar disregard for a child’s autonomy, they suggest in order to avoid further shame upon the child, medical photography should be taken whenever a child is already under anesthesia (Lee et al., 2006).

As members of the health care team who will interact with parents during this potential crisis, we have the responsibility to encourage them to really take the time to think about their decisions. We have the ethical duty to keep parents informed through clarification, research, options and counseling, and help them understand that many surgical interventions are irreversible and life-altering. As nurses for the childbearing family, we have the ethical responsibility to be educated in the initial management of newborns, their families, and their options (Lee et al., 2006).

We need to take it upon ourselves to understand that gender is culturally constructed and may be viewed differently from people of a different culture. It is suggested that “in most cases the birth of an infant with intersexuality is not a medical emergency. All efforts should be directed to reduce anxiety and support parent-infant bonding to allow time for adaptation and informed consent” (Thyne et al., 2005, p. 5). We must facilitate a transition that allows parents to understand that the most important decision that they can make for their child is the promise of love, acceptance, open communication and support. Assigning sex to a child is an ethical issue; accordingly, the concept of gender is not black and white, therefore it is okay to let our children live somewhere in the gray.

Future Directions

Within the medical field, we are a culture defined by science and technology, and then trend of today is to employ multimodal examinations to formulate a more educated assessment of an intersex infant.

Current guidelines suggest that physical examination can be followed by chromosomal evaluation, biochem-

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ical testing, radiographic imaging, diagnostic laparotomies, and finally, sex assignment. This diagnostic approach is married with warning label, however, that does stress that a cautious approach, with the consideration of reversible interventions (Baskin, 2008). As medical experts, by embracing a more accepting approach, we are moving in the right direction, however as a society at whole, candid discussion is the only way to rescue a topic deeply submerged, and allow some light to illuminate.

References Akhtar, J (2004). Assigning gender to babies with intersex anomalies. Journal of the College of Physicians and Surgeons-Pakistan. 14, 127.

American Nurses Association. (2005). Code of ethics for nurses with interpretive statements. In code of ethics for nurses. Retrieved January 31, 2009, from http://nursingworld.org/ethics/code/protected_ nwcoe813.htm.

Baskin L.S. (2008). Chapter 43. Abnormalities of Sexual Determination & Differentiation. In E.A. Tanagho, J.W. McAninch (Eds), Smith’s General Urology, 17e. Retrieved April 27, 2013 from http://www.accessmedicine.com/content. aspx?aID=3131473.

Eugenides, J. (2002). Middlesex. Ne York, NY: Farrar, Straus and Giroux.

Lee, P, Houk, C, Ahmed, F, & Hughes, L (2006).

Consensus statement on management of intersex disorders. Pediatrics, 118, 488-500.

Maharaj, N, Dhai, Wiersma, R, & Moodley, J (2005).

Intersex conditions in children and adolescents: Surgical, ethical and legal considerations. Journal of Pediatric and Adolescent Gynecology, 18, 399402.

Piper, T. (Ed.). (2008). Stedman’s medical dictionary for the health profession and nursing (6th ed.).

Philadelphia: Wolters Kluwer.

Thyen, U, Richter-Appelt, H, Wiesemann, C, Holterhus, P, & Hiori, O (2005). Deciding on gender in children with intersex conditions. Treatments in Endocrinology. 4, 1-8.

Ulrich, Connie. “Ethical Theories.” University of Pennsylvania. Philadelphia, PA. 14 January 2009.

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Footnote

1 For the scope of this paper, sex is defined as “the biological character or quality that distinguished male and female from one another as expressed by… gonadal, morphologic, chromosomal, and hormonal characteristics” (Piper, 2008, p. 1421). Not just determined by chromosomes or genitals, gender identity involves the interaction of hormonal influences, role behaviour, sexual orientation, and is “considerably modified by psychological, social and cultural factors” (Thyen et al., 2005 p. 1).

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Prenatal Care for Women with Serious Mental Illness Marissa DeCesaris, BSN Candidate Abstract The lifetime prevalence of serious mental illness (SMI) for women in the United States is nearly 6% (NIMH, 2012). Women in this group often have lifestyle and socioeconomic characteristics that lead to poor health status and delays in seeking heath care. While women with SMI are just as likely to have children as their non-mentally ill counterparts, they are more likely to experience pregnancy complications and negative birth outcomes. Prenatal care must take into consideration the unique needs of these women and the challenges they face. Recommendations for improving practice include increasing pregnancy screening, using multidisciplinary teams to provide holistic care, and involving the patient in shared decision-making. This care should be continuous throughout the woman’s childbearing years. Further research is needed to test the effectiveness of models of prenatal care tailored to women with SMI. Prenatal Care for Women with Serious Mental Illness

Nearly 6% of adult women in the United States will suffer from serious mental illness (SMI) in their lifetimes. The National Institutes of Health define SMI as “A mental, behavioral, or emotional disorder resulting in serious functional impairment which substantially interferes with or limits one or more major activities� (NIMH, 2012). This includes diagnoses such as schizophrenia, schizoaffective disorder, bipolar disorder, and major depressive disorder.

Women with SMI are generally in poorer health than their counterparts without SMI, due to effects of both mental illness treatment and lifestyle factors such as smoking and lack of exercise (De Hert et. al., 2011).

Socioeconomic factors such as unemployment and negative stigma that affect access to health care, especially primary and preventive care, further distinguish women with SMI from those without mental illness.

As recovery and community re-integration increasingly become the goals of mental health treatment, women with SMI are equally likely as those without SMI to become pregnant and have children.

Mental illness, especially clinical depression, usually strikes women during their prime childbearing years, making it likely that a woman with SMI will be receiving some form of mental health treatment during pregnancy. Research shows that women with SMI are more likely to have late entry into prenatal care, complications during pregnancy, and poor birth outcomes compared to women without mental illness (Jablensky, Morgan. Zubrick, Bower, & Yellachich, 2005; Nguyen et al., 2012). These disparities surrounding pregnancy Vol 6, Iss 1, 2012-2013

and childbearing in this population highlight a distinct need for improvements in prenatal care for women with SMI. Literature Review

Many studies examine the incidence of pregnancy complications and negative birth outcomes for women with SMI, with an emphasis on the effects of using psychiatric medication during pregnancy. Much of the research on this population is international, and healthcare systems in other countries differ greatly from those in the United States. One such study, conducted in Sweden, used prospective cohort data from a registry of over 1.5 million women to compare birth outcomes for mothers with affective psychosis to birth outcomes for unaffected mothers (MacCabe et al., 2007). Mothers with affective psychosis were more than twice as likely to have a preterm delivery, low birth weight, or stillbirth, even after controlling for maternal factors such as tobacco use. This study was somewhat limited due to exclusion of women with mental illnesses besides affective psychosis. However, studies of more inclusive populations consistently show higher rates of negative birth outcomes for women with SMI (Jablensky, et al., 2005; Nguyen, et al., 2012).

A 2010 literature review compiled original research, previous reviews, and existing guidelines for prenatal care for women with bipolar disorder and schizophrenia. Based on the results of this review and input from relevant providers, the authors developed a set of guidelines for clinicians treating this population.

These guidelines cover aspects of prenatal care beyond

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medication management such as maternal nutrition, screening for fetal abnormalities, and advance planning for delivery and post-partum care. There is a strong focus on identifying and managing risks for potential complications early in prenatal care, as women with SMI require enhanced monitoring of maternal and fetal condition throughout pregnancy (Galbally, Snellen, Walker, & Permezel, 2010).

Few studies explore specific models of care designed to improve outcomes for childbearing women with SMI. One successful program, studied by Nguyen et. al. (2010), is the Childbirth and Mental Illness Antenatal Clinic (CAMI) in Western Australia. This clinic uses multidisciplinary teams of obstetrics, nurse midwives, social workers, and psychiatrists to care for women with SMI before, during, and after pregnancy. This study used a retrospective cohort design to explore treatment outcomes of women receiving prenatal care at CAMI. Results showed a reduction in depression and anxiety symptoms over the course of treatment at CAMI, measured by the Edinburgh Postnatal Depression Scale. Women in the study attended 90% of scheduled prenatal visits, with an average of 9.4 visits per person. Another study of the same clinic found the number of prenatal visits per woman attending CAMI to be equivalent to that of the general Western Australia population (Nguyen, et al., 2012).

Recommendations

Based on findings from current research, pregnancy outcomes for women with SMI are best when care is holistic, multidisciplinary, and continuous. During the woman’s childbearing years, this care begins with family planning and education about prospective pregnancy. Women with SMI have higher rates of unplanned pregnancy and HIV than the general population, and information about safe sex and family planning should be incorporated into regular care (Miller & Finnerty, 1996). Additionally, the risk of teratogenic effects from psychiatric medications is highest during the first eight weeks of pregnancy, thus all women with SMI must be advised of this risk prior to conception. With estimates of late entry into prenatal care as high as 49%, women with SMI of childbearing age should consistently be screened for pregnancy more frequently at mental health clinics and upon hospital admission for a psychiatric condition (Kim, Mandell, Crandall, Kuskowski, Dieperink, & Buchberger, 2006; Miller, 1997).

Once a woman with SMI enters prenatal care, a multidisciplinary team should be established to proVol 6, Iss 1, 2012-2013

vide ongoing mental and physical health care. Similar to the approach used at the CAMI clinic, the team should include a midwife, psychiatrist, case manager, and obstetric specialist, and bridge the gaps between outpatient and inpatient care. The care plan should involve shared decision-making among the healthcare team, patient, and patient’s family or support system. The article written by McCullough, Coverdale, and Chervenak (2002) outlines seven steps for ethical decision making with pregnant women with SMI. Shared decision-making is especially important when discussing the use of psychiatric medication during pregnancy, because the risks and benefits are unique to each patient. It is also important for nurses and other providers to not let negative stigma cloud their guidance of women with SMI. They should not view pregnancy as a negative event in the woman’s life but rather a positive experience with a chance for the woman to increase her responsibility and self-efficacy (Miller & Finnerty, 1996).

Several barriers exist to applying these recommendations to practice, beginning with a lack of awareness of the number of women with SMI who become pregnant and successfully raise children. Providers should offer unbiased, evidence-based advice to women and help them understand all available choices (Galbally et al., 2010). Second, multi-disciplinary teams are time and resource-intensive, and most physical and mental health providers lack specific training in prenatal care for this population. Some psychiatric facilities may even refuse to admit pregnant women because they are not equipped to treat pregnancy and delivery complications (Miller, 1997). Overall access to health care is often restricted for this population due to the financial and social barriers that typically accompany SMI. Furthermore, since SMI often affects cognitive processes, patient education and shared decision-making strategies may require modification (Desai & Chandra, 2009). Patient education should focus on a few key points at each visit, using concrete language that is easier for patients to comprehend than abstract concepts.

Conclusions

Based on the current state of the science, it seems that there is a need for system-level improvement in coordinating prenatal care for this distinct group of women. As patient advocates, nurses have an especially important role in shared decision-making.

Nurses help determine whether or not to discontinue psychiatric medication during pregnancy, assess the

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parenting competency of women with SMI, and support patient decisions in the face of pressure from spouses and other providers. Nurses also function as part of a multidisciplinary team and assist with coordination of care between physical and mental healthcare providers. There are currently very few clinics that specifically address the unique needs of childbearing women with SMI, and further research is needed to establish these models of care as evidence-based practice. As the concept of the medical home becomes more popular, it will be interesting to see if this model is adapted to provide holistic care for this population.

Women with SMI can, with proper prenatal care and support, successfully give birth to healthy babies, and nurses can lead the way to ensuring positive outcomes for all of these women.

References De Hurt, M., Corell, C.U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I.,Leucht, S. (2011).

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications disparities in health care World

Psychiatry, 10(1): 52-77.

Desai, G., & Chandra, P.S. (2009). Ethical issues in treating pregnant women with severe mental illness. Indian Journal of Medical Ethics, 6(2): 75-77.

Galbally, M., Smellen, M., Walker, S., & Permezel, M. (2010). Management of

antipsychotic and mood stabilizer medication in pregnancy: Recommendations

for antenatal care. Australian and New Zealand Journal of Psychiatry, 44: 99-108.

Jablensky, A.V., Morgan, V., Zubrick, S.R., Bower, C., & Yellachich, L. (2005). Pregnancy, delivery, and neonatal complications in a population cohort of women

with schizophrenia and major affective disorders.

American Journal of

Psychiatry, 162(1): 79-91.

Kim, H.G., Mandell, M., Crandall, C., Kuskowski, M.A., Dieperink, B., & Buchberger,

R.L. (2006). Antenatal psychiatric illness and adequacy of prenatal care in an

ethnically diverse inner-city obstetric population.

Archives of Women’s Mental

Health, 9: 104-107.

MacCabe, J.H, et al. (2007). Adverse pregnancy outcomes in mothers with affective Vol 6, Iss 1, 2012-2013

Psychosis. Bipolar Disorders, 9(3): 305-309.

McCullough, L.B., Coverdale, J.H., & Chervenak, F.A. (2002). Ethical challenges of decision making with pregnant patients who have schizophrenia. American Journal of Obstetrics and Gynecology, 187(3): 696-702.

Miller, L.J., & Finnerty, M. (1996). Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders. Psychiatric Services, 47(5): 502-506.

Miller, L.J. (1997). Sexuality, reproduction, and family planning in women with

schizophrenia. Schizophrenia Bulletin, 23(4): Nguyen, T.N., Faulkner, D., Allen, S., Hauck, Y.L., Frayne, J., Rock, D., & Rampono, J.(2010).

Managing pregnant women with serious mental illness: Using the Edinburgh Postnatal Depression Scale as a marker of anxiety and depressive symptoms. Australian and New Zealand Journal of Psychiatry, 44: 1036-1042.

Nguyen, T.N., Faulkner, D., Allen, S., Hauck, Y.L., Frayne, J., Rock, D., & Rampono, J. (16 April 2012). Obstetric and neonatal outcomes of pregnantwomen with severe mental illness at a specialist antenatal clinic. Medical Journal of Australia Open 1, Supp1: 26-30.

U.S. Department of Health and Human Services, National Institute of Mental Health,National Institutes of Health, (2012). Prevalence of serious mental illness among U.S. adults by age, sex, and race.

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The Physical and Mental Health Effects of Community Violence Exposure in Pre-Adolescent and Adolescent Youth Sarah W. Fairbrook, BSN, RN Abstract The purpose of this inquiry is to determine the impact of community violence exposure (CVE) on the physical and mental health of children and adolescents. Twelve research studies exploring this topic were found by conducting a search in Pubmed and the Cumulative Index of Nursing and the Allied Health Literature (CINAHL).

The articles used in this inquiry were limited to those published in the United States after 2003. All studies directly assessed CVE and explored its association with psychological or physical symptoms. An increased risk of PTSD and internalizing symptoms were associated with CVE. Children with CVE were at a higher risk for somatic complaints. In addition, CVE was associated with higher morbidity in children with asthma. The literature was entirely self-report with both cross-sectional and longitudinal studies. These results indicate the need for further research to better understand CVE and health associations.

Ethical Perspectives Regarding Antidepressant Drug Therapy During Pregnancy Introduction

Violence is an epidemic in the United States with widespread consequences. In 2011 alone, there were approximately 1,203,564 violent crimes nationwide, the highest number occurring in large cities (Uniform Crime Report, 2012). It is estimated that the United States spends 15% of its gross domestic product (GDP) on containing violence (“Violence Containment Spending” 2012). It affects the community in profound ways, decreasing property values, reducing productivity, and increasing health care costs (Center for Disease Control and Prevention, 2012). Reducing violence has been recognized by the Center for Disease Control and Prevention (CDC), the Surgeon General’s National Prevention Council (NPC), and Healthy People 2020 as a top priority for improving public health and safety in the United States.

Youth are directly affected by the prevalence of violent crime. Violence contributes to high rates of injury and death in young people in the US, with 16 adolescents aged 10-24 murdered each day and 700,000 emergency department visits due to violent assault each year (CDC, 2012). In addition, adolescents have high rates of violent crime arrests especially among males ages 15-19 among whom the rate is 730.3 per 100,000 (Uniform Crime Report, 2012).

Gang violence and membership remain high with an approximate 756,000 gang members in 2010 (National Gang Threat Assessment, 2011).

Direct victimization and participation are not Vol 6, Iss 1, 2012-2013

the only way that violence impacts American children and youth. Approximately 60% of children 17 and under were exposed to some sort of violence over the span of one year, and lifetime exposure rates are two to three times higher (Finkelhor, Turner, Ormrod, Hamby & Kracke, 2009). Children and adolescents living in poverty are at an increased risk for violence exposure (National Prevention Council, 2011).

The full effects of violence exposure in children and adolescents are complex. Much of the previous research in this field has focused on the effects specifically of domestic violence exposure and direct victimization. The implications of exposure to community violence are still not fully understood. This review seeks to synthesize the current body of literature regarding the physical and mental health effects of community violence exposure (CVE). Community Violence Exposure is a broad classification of many types of exposures to violence including direct victimization, witnessing, and hearing about violence within a community. In this paper, the relationship of community violence exposure to internalizing behavioral problems and somatic complaints are the focus because their associated symptoms are common reasons for youth to present for health care. Increased understanding of the health effects of CVE will allow for improved health care screening, diagnosis, and treatment. Further research in this field has the potential to inform violence prevention efforts and direct policy at local, state and national levels.

Methods

A literature search was performed using

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PubMed and the Cumulative Index of Nursing and the Allied Health Literature (CINAHL). The search terms used were community violence, community violence and youth, community violence and health, community violence and asthma, and urban violence. More than 100 articles resulted from these search terms. Of these results, only articles from the United States were retained due to the confounding potential of social and cultural differences. The results were further limited to those involving youth ages 0-18 and published after 2003. From the remaining collection of articles, only those that were research studies and focused on internalizing symptoms and physical health manifestations were retained. Exclusively articles assessing the association between community violence exposure and internalizing symptoms or physical health were included.

Key variables included in this analysis are post-traumatic stress disorder (PTSD), somatic complaints, asthma, and general health status. PTSD is a mental disorder that is grounded in a traumatic event and to which individuals experience problematic symptoms (intrusive thoughts, avoidance, hyperarousal) that extend for more than one month after the event and interfere with normal life activities. Somatic symptoms refer to a variety of physical symptoms that an individual may experience. Common complaints include stomachache, headache, decreased appetite, difficulty sleeping. Somatic symptoms may or may not have underlying medical explanations.

The term is often associated with physical manifestations of psychosocial issues. Asthma is a chronic inflammatory disorder of the airways. In the United States, asthma is found in higher rates among children, minority populations, and those with a family income below the poverty level. (Akinbami, Moorman & Liu, 2011). Asthma accounts for approximately a quarter of all emergency department visits in the US. High-risk populations for asthma are also among the populations at risk for increased community violence exposure. General health status considers a variety of health indicators. The studies reviewed here took into account physical and mental health in addition to socio-economic situation and environment. Health was determined by self-report and no medical records were reviewed.

Results

The relationship of community violence exposure to mental and physical health was analyzed. The mental health impacts explored in the studies included Vol 6, Iss 1, 2012-2013

PTSD and the internalizing symptoms of depression and anxiety. The physical health impacts that were analyzed include somatic symptoms such as cough, stomachache, poor appetite, and difficulty sleeping.

The association between CVE and asthma was examined. General health status was also considered in relation to CVE. PTSD

Two studies examined the association between CVE and PTSD. Fowler, Tompsett, Braciszewski, Jacques-Tiura, and Baltes (2009) synthesized data from 114 studies in their meta-analysis. They found a significant association between community violence exposure and PTSD. The effect size was greater for more recent exposures. The proximity of the community violence (victimization, witnessing, hearing, etc.) did not have an effect on PTSD symptoms. In fact, community violence victimization, witnessing, and hearing were equal in predicting PTSD symptoms.

Hunt, Martens, and Belcher (2011) conducted a retrospective cohort study using the medical records of 257 African American children, and found that exposure to community violence was associated with higher levels of PTSD. Children who had been exposed to community violence were 2.6 times as likely to display clinically significant PTSD symptoms with a 95% confidence interval of [1.19, 5.65]. Community violence exposure had a similar association to PTSD as being a victim of physical abuse and a stronger association than being a witness to domestic violence.

Internalizing Symptoms: Depression and Anxiety

Five studies examined the association between internalizing symptoms and CVE. Fowler et al.

(2009) found in their meta-analysis that the association of CVE to internalizing symptoms is dependent on multiple factors including the recency and proximity of exposure, and relationship to the victim. The effect of CVE on internalizing symptoms was stronger with more recent exposures and was directly related to the proximity of the exposure, with witnessing more proximal than hearing (Fowler et al., 2009).

Gaylord-Harden, Cunningham, and Zelencik (2011) conducted a cross-sectional study of 278 African American youth receiving free or reduced lunches in five Mid-Western inner-city public schools. They found a curvilinear association between community violence exposure and depression in inner-city, African American youth. The association leveled off and ultimately decreased with persistent accumulation of violence exposure. Community violence exposure

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was found to have a dose-dependent effect on depressive symptoms and anxiety in a mixed-race sample of children and families. Accumulation of community violence exposures was associated with higher rates of depression and anxiety.

Margolin, Vickerman, Oliver, and Gordis (2010) performed a longitudinal cohort study involving 98 families with at least one child age nine or ten at the beginning of the three-year study. High levels of exposure to community violence were associated with twice the rates of depression and anxiety (Margolin et al., 2010). This is consistent with the finding that internalizing symptoms in children and adolescents were predicted by total community violence exposure (Fowler et al., 2009).

Lambert et al. used a cross sectional study design involving 501 tenth graders of which 87% were African American and 13% were European American.

Among this cohort, no relationship was found between witnessing community violence against a stranger and depressive symptoms. However, witnessing violence against a family member or close friend showed a strong positive association with depressive symptoms (Lambert et al., 2012). Anxiety was strongly associated with witnessing community violence against a family member in both genders. Among males, witnessing violence against a close friend was associated with anxiety; among females, witnessing violence against an acquaintance was associated with anxiety.

Finally, Hertwick, Ziegler, and Logsdon (2010) performed a cross-sectional cohort study of 100 adolescent females: 39 predominantly African Americans of low socioeconomic status, and 61 predominantly middle class Caucasians. They found an association between depressive symptoms and CVE for the entire population. The association was equal between the sample of low-income, predominately African-Americans recruited from a teen clinic and the predominantly Caucasian college freshmen sample. However, the low-income teens did not experience the mediating effect of social support found in the college freshmen sample. This evidence suggests that socio-economic status may impact the effect of mediating factors after CVE.

Community violence exposure was consistently found to be associated with the internalizing symptoms of depression and anxiety in youth. The severity of the depressive symptoms is dependent on the cumulative exposure to community violence. The behavior of the association as the cumulative violence Vol 6, Iss 1, 2012-2013

exposure increased was slightly different in two studies.

Somatic Complaints

Two studies examined the association between CVE and somatic symptoms. Bailey et al. (2005) used a cross-sectional cohort design with a sample of 268 African-American children. Somatic complaints such as stomachaches and headaches are positively associated with community violence exposure. Bailey et al. (2005) found that community violence exposure in children was associated with a 28% increased risk of appetite problems, 94% increased risk of sleeping problems, 57% increased risk of headaches, and a 174% increased risk of stomachaches. These results were based on children’s self-report as well as teacher report.

Hart, Hodgkinson, Belcher, Hyman, and Cooley-Strickland (2012) also conducted a crosssectional cohort study using a sample of 409 primarily African American (85.6%) urban elementary school children. In this study, they measured CVE by child self-report. Information regarding somatic complaints was collected in two ways: by child self-report and by parent report. Hart et al. (2012) found that community violence exposure was positively associated with children’s self-reports of somatic complaints. Children reporting community violence exposure were at an increased risk for self-reported, clinically significant somatic complaints; however, community violence exposure as measured by child report was not associated with parents’ reports of children’s somatic symptoms. This indicates the likelihood that in children, the perception of violence is more important than the actual presence of violence. Therefore, the perception is what is linked to the somatic complaints. In fact, when community violence was measured using objective data on crime such as murder, theft, and assaults, there was no association with somatic complaints.

Asthma

Two studies examined the association between CVE and asthma. Wright et al. (2004) performed a cross-sectional cohort study with a sample of 937 children aged 5-12 with asthma recruited from seven major cities who had at least one hospitalization or two emergency room visits during the six months before screening. After controlling for income, employment status, caretaker education, housing problems, and other life events, community violence exposure was positively associated with increased asthma morbidity as measured by wheezing, sleep disruption, and inter-

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ference with activities.

Walker, Lewis-Lad, Kub, Tsoukleris, and Butz (2008) conducted a longitudinal cohort study of 231 urban caregivers with children ages 5-12 with asthma.

Among 231 predominantly African American children with asthma, community violence exposure as reported by caregivers was associated with increased frequency of night symptoms (Walker et al., 2008). This is consistent with the results of Wright et al. (2004) in their study of 937 inner-city children with asthma.

General Health Status

Two studies looked at the association between CVE and overall health, and the effect of CVE on general health status was unclear. Fredland, Campbell, and Han (2008) used a cross-sectional predictive correlational model with their sample of 309 predominantly African American 7th graders. The model used by Fredland et al. (2008) found no significant effects of CVE on overall health status among 890 urban middle school students, whereas domestic violence exposure, direct victimization and coping did have a significant impact. Health encompassed physical, mental, and behavioral symptoms.

Boynton-Jarrett, Ryan, Berkman and Wright (2008) used a nationally representative sample of 8984 youths aged 12-18 for their longitudinal cohort study.

Contrary to Fredland et al. (2008), they found a graded increase of self-reported poor health with increased cumulative violence exposure. These results are more convincing due to the large, nationally representative sample size. More studies are needed to confirm these findings.

Gender

The mediating effect of gender is not consistent throughout the results. It is unclear if there were gender differences in PTSD symptoms associated with community violence exposure. Fowler et al. (2009) found no significant differences between males and females in prevalence of PTSD symptoms. This contradicts the results of Hunt et al., who found an association between female gender and increased prevalence and severity of PTSD symptoms.

Gender has an important impact on internalizing symptoms. Fowler et al. (2009) determined that all female samples generated higher rates of internalizing symptoms than all male samples. Lambert et al. (2012) found that females reported higher rates of anxiety and depressive symptoms than males. Gaylord-Harden et al. (2011) found that their curvilinear association between community violence exposure and Vol 6, Iss 1, 2012-2013

depressive symptoms was only statistically significant in males. On the contrary, females displayed a positive linear association between community violence exposure and depressive symptoms, similar to anxiety.

This may be due to a numbing effect in males after repetitive exposure to violence that does not occur in females. The linear association between CVE and anxiety held true for both males and females.

Age

Age-related differences exist in the type and magnitude of effects of community violence exposure.

Boynton-Jarrett found that early violence exposure had a greater impact than adolescent exposure on poor self-reported health. In the association between CVE and PTSD, there were no differences in prevalence between children and adolescents (Fowler et al., 2009; Hunt et al. 2011). Age seemed to have the greatest mediating effect on somatic complaints. Hart et al.

(2012) found an adjusted 38% decrease in odds of somatic symptoms for every year older the child was.

Summary

Overall, the empirical evidence suggests that there are significant mental and physical health consequences associated with CVE. Increased risk for PTSD symptoms is associated with CVE. Internalizing symptoms are positively associated with CVE and are dependent on the cumulative exposure. CVE was linked to increased risk of somatic complaints, and asthma morbidity is higher in children with CVE. Discussion Limitations

Research in the field of community violence exposure is still in its infancy with much room to grow. One of the greatest limitations in synthesizing the current body of literature is the inconsistency of community violence exposure measurements. The determination of CVE ranged from validated measures to a set of questions specific to one study. For example, Bailey et al. (2005) used the “Things I’ve seen and Heard” 5-point scale self-report questionnaire which consists of 20 questions determining type and frequency of exposure to violence when investigating the association between somatic symptoms and CVE. Hart et al. (2012) studied the same association but used the Children’s Report of Exposure to Violence, a 29-item questionnaire assessing children’s selfreported exposure to community violence. The different measures of CVE make it difficult to compare results. Fowler et al. lists the variety of measures of CVE as one of the limitations to their meta-analysis.

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Other validated measures used in the studies included the Multicultural Events Schedule for Adolescents, an 82-item self-report measure of stress for adolescents living in an urban environment, the Survey of Exposure to Community Violence Scale.

Another common limitation in these studies is the reliance on self-report in measuring both CVE and health status. This can have a significant impact on the accuracy of results. Hart et al. found that the parental reports of children’s somatic symptoms differed greatly from the children’s self-report as did their reports on CVE. This makes it difficult to draw conclusions about the association between CVE and somatic symptoms, though it does provide insight on the effects of perception.

Subsequent studies should involve more diverse samples. Most of the studies used for this review examined samples of predominantly low-income, urban, African American. This may reflect a societal belief that community violence is an urban problem associated with low-income, under-resourced areas, which tend to be populated with racial minorities.

This has the potential to build into a dangerous stereotype that community violence is a minority problem.

Further, it has the potential to indicate that community violence is not present anywhere else, a view unsubstantiated by data. In order for results to be generalizable, studies must include a variety of ethnicities, races, and socio-economic groups. This information will also be important for understanding mediating factors and developing appropriate interventions.

Research Implications

Future research needs to focus on developing a common measurement of CVE. The measure should be able to account for the different types of violence, the proximity of the violence, the relationship to the victim, and the recency of the exposure. Future studies should further seek to determine if exposure to different types of violence has different outcomes. In addition, it will be important to further illuminate the mediating factors involved, as more is understood about the specific impacts of CVE. Future studies should seek to understand which factors help decrease the negative impact of CVE. Ultimately, it will be important to test the efficacy of various interventions at the individual, family, and community level in reducing the negative effects of CVE. Clinical Implications

There is convincing evidence that CVE has a significant impact on physical and mental health in Vol 6, Iss 1, 2012-2013

low-income, urban, African-American youth. While remaining sensitive to the potential racial and/or socioeconomic bias of the current research, this information can still inform clinical practice in several ways.

Youth should be screened for their perceived levels of CVE. Those reporting exposure should be screened for PTSD, internalizing symptoms and somatic symptoms, and conversely, youth presenting with psychological or somatic symptoms should be screened for CVE. Youth diagnosed with asthma having significant CVE may need to be followed more closely to ensure that symptoms are being controlled. Finally, clinicians should seek education about PTSD, depression, and anxiety in order to provide effective interventions and referrals as needed.

Policy Implications

Evidence of the negative effects of CVE on physical and mental health demonstrates the need for increased violence prevention efforts. Cities should focus on improving the economic viability of low-income neighborhoods with high rates of violent crime.

The effects of CVE on mental health should help inform the practices of the juvenile criminal justice system especially when re-initiating youth into a community with high rates of violence. Further research in this field may also inform firearm policy as it relates to public health. The government should continue its efforts to reduce violence in the United States through education and initiatives carried out by the CDC, NPC, and Healthy People.

Conclusion

Despite limitations of sampling and self-report, current research suggests an association between CVE and health in low-income, urban, African-American youth. In this population, CVE has been associated with PTSD, depression, and anxiety. In addition, CVE has an impact on somatic symptoms and asthma morbidity. Effects of race, socioeconomic status, gender and age are still unclear and merit further research. As this field of research grows and associations are better understood, interventions can be developed both for treatment and prevention. Policy at all levels should compliment these efforts by attempting to reduce violence through legislative action. Violence continues to be problem of epidemic proportions in the United States, and its full impacts are only beginning to be understood. With prevention, treatment, and violence reduction efforts, public health can be significantly improved and health care costs reduced. Understanding the effects of community violence exposure is impera-

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tive to developing healthy youth and a healthy country.

Medicine, doi: 10.1007/s10865-012-9440-2 Hertweck, S. P., Ziegler, C. H., & Logsdon, M. C. References (2010). Outcome of exposure to community vioAkinbami, L.J., Moorman, J.E., Liu, X. (2011). Asthlence in female adolescents. Journal of Pediatric ma Prevalence, Health Care Use, and Mortality: and Adolescent Gynecology, 23(4), 202-208. doi: United States, 2005-2009. National Health Statis10.1016/j.jpag.2009.11.002 tics Reports, 32. Retrieved from http://www.cdc.

Hunt, K. L., Martens, P. M., & Belcher, H. M. (2011). gov/nchs/data/nhsr/nhsr032.pdf Risky business: Trauma exposure and rate of Bailey, B. N., Delaney-Black, V., Hannigan, J. H., posttraumatic stress disorder in african american Ager, J., Sokol, R. J., & Covington, C. Y. (2005). children and adolescents. Journal of Traumatic Somatic complaints in children and community Stress, 24(3), 365-369. doi: 10.1002/jts.20648; violence exposure. Journal of Developmental and 10.1002/jts.20648 Behavioral Pediatrics : JDBP, 26(5), 341-348.

Institute for Economics & Peace. (2012) Violence Boynton-Jarrett, R., Ryan, L. M., Berkman, L. F., & Containment Spending in the United States: A Wright, R. J. (2008). Cumulative violence expoNew Methodology to Categorize and Account sure and self-rated health: Longitudinal study of for the Economic Activity Related to Violence. adolescents in the united states. Pediatrics, 122(5), Retrieved from http://www.visionofhumanity.org/ 961-970. doi: 10.1542/peds.2007-3063 wp-content/uploads/2012/09/Violence-ContainCenters for Disease Control and Prevention (2012). ment-in-the-US-Report.pdf Understanding Youth Violence: Fact Sheet. ReLambert, S. F., Boyd, R. C., Cammack, N. L., & trieved from http://www.cdc.gov/ViolencePrevenIalongo, N. S. (2012). Relationship proximity tion/pdf/YV_FactSheet2012-a.pdf to victims of witnessed community violence: Associations with adolescent internalizing and Finkelhor, D., Turner, H., Ormrod, R., Hamby, S., & externalizing behaviors. The American Journal of Kracke, K. (2009). Children’s Exposure to VioOrthopsychiatry, 82(1), 1-9. doi: 10.1111/j.1939lence: A Comprehensive National Survey. Juve0025.2011.01135.x; 10.1111/j.1939nile Justice Bulletin. Retrieved from https://www.

0025.2011.01135.x ncjrs.gov/pdffiles1/ojjdp/227744.pdf Margolin, G., Vickerman, K. A., Oliver, P. H., & GorFowler, P. J., Tompsett, C. J., Braciszewski, J. M., dis, E. B. (2010). Violence exposure in multiple Jacques-Tiura, A. J., & Baltes, B. B. (2009). interpersonal domains: Cumulative and differenCommunity violence: A meta-analysis on the tial effects. The Journal of Adolescent Health : effect of exposure and mental health outcomes Official Publication of the Society for Adolescent of children and adolescents. Development and Medicine, 47(2), 198-205. doi: 10.1016/j.jadoPsychopathology, 21(1), 227-259. doi: 10.1017/ health.2010.01.020 S0954579409000145 National Gang Intelligence Center. (2011) National Fredland, N. M., Campbell, J. C., & Han, H. (2008).

Gang Threat Assessment: Emerging Trends.

Effect of violence exposure on health outcomes Retrieved from http://www.fbi.gov/stats-seramong young urban adolescents. Nursing Revices/publications/2011-national-gang-threatsearch, 57(3), 157-165. assessment/2011-national-gang-threat-assessmentGaylord-Harden, N. K., Cunningham, J. A., & Zelenemerging-trends cik, B. (2011). Effects of exposure to community violence on internalizing symptoms: Does desen- National Prevention Council. (2011). National Prevensitization to violence occur in african american tion Strategy. Retrieved from http://www.healthyouth? Journal of Abnormal Child Psychology, care.gov/prevention/nphpphc/strategy/report.pdf 39(5), 711-719. doi: 10.1007/s10802-011-9510-x Hart, S. L., Hodgkinson, S. C., Belcher, H. M., HyUnited States Department of Justice, Federal Bureau man, C., & Cooley-Strickland, M. (2012). Somatof Investigation. (2012) Uniform Crime Report ic symptoms, peer and school stress, and family 2011. Retrieved from http://www.fbi.gov/aboutand community violence exposure among urban us/cjis/ucr/crime-in-the-u.s/2011/crime-in-theelementary school children. Journal of Behavioral u.s.-2011/violent-crime/violent-crime Vol 6, Iss 1, 2012-2013

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Walker, J., Lewis-Land, C., Kub, J., Tsoukleris, M., & Butz, A. (2008). The effect of violence on asthma: Are our children facing a double-edged sword?

Journal of Community Health, 33(6), 384-388.

Wright, R. J., Mitchell, H., Visness, C. M., Cohen, S., Stout, J., Evens, R., Gold, D.R. (2004). Community Violence and Asthma Morbitity: the InnerCity Asthma Study. Am. J. Public Health, 94 (4), 625-632.

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Mary Kate Lapinel President of OSNR lapinel@nursing. upenn.edu

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JONSR is a publication of the Organization of Student Nursing Research. Copyright Š 2013 OSNR. The contents of this journal should not be reproduced or reprinted without the permission of the Journal of Nursing Student Research or its authors. All rights reserved.

Special Thanks to: Kathleen McCauley, PhD, RN, ACNS-BC, FAAN, FAHA Class of 1965 25th Reunion Term Professor of Cardiovascular Nursing and Associate Dean for Academic Programs University of Pennsylvania School of Nursing Patricia D’Antonio, PhD, RN, FAAN Killebrew-Centis Endowed Term Chair in Undergraduate Education, Chair, Department of Family and Community Health University of Pennsylvania School of Nursing Christopher Lance Coleman, PhD, MS, MPH, APRN-BC, ACRN, FAAN Fagin Term Associate Professor of Nursing and Multi-Cultural Diversity, Associate Professor of Nursing in Psychiatry, School of Medicine Members of the JOSNR Faculty Editorial Board The Doctoral Student Organization’s Paule Valery Joseph and Sarah Abboud Support of the Penn Nursing Community