Advanced Practice Nursing

The evolution of the term “advanced” in nursing is unclear, several fellow colleagues have asked me what does it mean to have a Master’s degree in nursing and what does specifically a nurse at a Master’s level is entitled to do. Indeed, it is a tough question since it’s almost impossible to have a short and concise answer that captures what nurses actually do. However, I will try as much as I can to give you an overview of the commonalities of the various advanced practice specialties in nursing and I will specifically elaborate on the role of Advanced Practice Psychiatric Nursing (APPN).

Some assume that the end point of a graduate degree in nursing is an administrative or managerial position; while this could be a very prospective role it is not exclusive to nursing advancement. In the American University of Beirut (AUB)  we have 4 specialization tracks at a Master’s level accredited by the Commission on Collegiate Nursing Education (CCNE) and they include: MSN in nursing administration, MSN in adult care, MSN in community nursing, and MSN in psychiatric mental health nursing. Furthermore, postgraduate training and certification are encouraged for nurses at a Master’s level who wish to deepen their proficiency in their practice. Advanced development in nurses’ role has emerged because of the complexity of the health care knowledge and technology. In Fact, the historical context of advanced nursing practice is very broad and encompasses health manpower and sociopolitical issues.

Advanced nursing practice has reached high levels of demand after World War I and II with the increasing case reports about war-related psychiatric problems in returning soldiers. Thus, with escalating public recognition of mental health concerns, psychiatric nursing was able to make major strides in the development of a specialized direct care role. By 1946, the National Mental Health Act designated psychiatric nursing as a core discipline and during the early 1950s, the primary contributor to mental health law reform, Hildegard Peplau has published the middle-ranged nursing theory of interpersonal relations that helped revolutionize the apprenticeship of psychotherapy. In 1980, the American Nurses Association (ANA) have reported that specialization in nursing is now clearly established and that specialization is a mark of development in the nursing profession. Advanced practice psychiatric nursing (APPN) is one of the oldest and most highly-developed clinical specialties in nursing, this expansion in the psychiatric nursing body of expertise provided the support for mental health nurses to begin seeking new management roles while gaining the attention of mental health patients as well as policy makers.

The spheres of influence of the APPNs are improving in function to the escalating need. Unfortunately, in Lebanon there still exist a big gap between what APPNs can actually do and what they are credentialed for. The nursing practice law in Lebanon does not recognize advanced practice; excluding AUB Medical Center, employers are not aware of the important roles that an advanced practice nurse can have in enhancing patient safety and improving quality of care. APPNs assess, diagnose, plan treatment, implement psychotherapy and evaluate the mental health of patients. One of the many assets nurse psychotherapists encloses patience, primarily because of their work experience with the chronically ill. In addition, nurses respect others’ limitations and follow a holistic paradigm of care; they are resourceful (both BSN and MSN programs have extensive pathophysiology and pharmacology courses) and ethical. In 2012, and for the 11th year in a row, the Gallup poll found that nurses top the list of the most ethical profession. Moreover, advanced nurses contribute to quality care improvement, academia, research, and policy development in health reform.

There is, without a doubt, an increasing need of the community for advanced nurses on all levels: practice, education, and management. Nurses continue to play a significant role in everyone’s daily life. Many nurses have changed lives and some of them have managed to change the course of a nation. Clara Barton was the founder of the American Red Cross, Dorothea Dix founded the first American mental hospital, Margaret Sander is one of the pioneers in teaching Planned Parenthood, and Anna Carolina Maxwell the founder of the Army Nurse Corps who bravery cared for wounded men and was a major force in improving the sanitary conditions in military hospitals. With the advancement in nursing practice, nurses will continue to be a key workforce in making this world a safer place to live.


Envy as a fragile Infant ego responding to a deprivation of some kind

            The best way to understand envy is to see it as the angry feeling the other person possesses, and is keeping it for himself. Also this other person is perceived as a reliable source of what one desires. The result is that this other person is seen as is keeping for themselves that thing “I want”.

            The envious impulse is to attack, or spoil the very source that one originally relied upon for what was desired. In the infant, the feeling of failed gratification is experienced as the breast withholding, or keeping for itself, the object of desire. Envy is therefore more basic than jealousy, and is one of the most primitive and fundamental of emotions. Envy stems from an immature intolerance of frustration. Melanie Klein found that the first object to be envied was the “breast”. This is the primary envy and if tolerated, and worked through, will lead to a normal development. But when the experience of envy is excessive (i.e. a failure in a good enough mothering) this can lead to a weakened ego. The mechanism of envy involves attacking the good “breast”, which results with introjections no longer occurring. In envy, there is an aim to possess the good object, but when this is felt to be impossible, the aim becomes a need to spoil the goodness of the object, in order to remove the source of envious feelings. Consequently, envy is the diabolical impulse to destroy the very source of goodness that maturation and growth will continue to require. Moreover, this primitive envy can be re-experienced in later childhood and adulthood as unconscious envy, and is likely to be revived in the therapeutic alliance as a negative transference.

Dangers of envy

            Defenses against envy that are unable to contain it will quickly lead to psychopathology, because they fail to prevent the destructive operation of envy, and its consequences in the weakening of the ego. Unresolved primary envy can lead to psychotic symptoms in the later life. Envy is commonly accompanied by self-pity, self-destructiveness, will turn inwards. The ego can implode and destroy itself. Suicidal feelings may be later expression of the early need to self destroy which the infant cannot express for itself.  The qualities that might manifest in the envious person are: persecution, frustration, guilt, self pity, idealization, acting out, ambition, inability to enjoy, disapproving, aggression, manic defenses, intolerance, hatred, destructiveness, self-destructiveness, sabotaging, discounting, suicidal ideation, etc.


Suggested reading:

Gericke, R. (2006). Working with a child’s envy in the transference. Journal Of Child & Adolescent Mental Health, 18(2), 73-78

Adolescents with Anti-Social Personality

Adolescents with antisocial personality disorder seem to have difficulties in taking into account all the relevant information in social interactions, such as other people’s intentions. The researchers hypothesize that this in turn leads to more antisocial behavior.

Adolescents with antisocial personality disorder inflict serious physical and psychological harm on both themselves and others. However, little is yet known about the underlying neural processes. Researchers at the University of Leiden and the Max Planck Institute for Human Development have pinpointed a possible explanation: Their brain regions responsible for social information processing and impulse control are less developed.

The study focused on incarcerated delinquent adolescents from the Netherlands aged between 15 and 21 years who had been diagnosed with an antisocial personality disorder. The researchers had the adolescents play the mini-ultimatum game. In this cooperative game, which simulates fairness considerations, the player is offered a sum of money by another player. The player is also told whether the opponent could have made a fairer offer or had no alternative.

Brain activity during the game was measured using functional magnetic resonance imaging (fMRI). By comparing the findings with those of a control group of nondelinquent adolescents, the researchers were able to determine what was going on in participants’ brains in the context of fairness considerations.

“No” to unfair offers

The delinquent adolescents showed less activation than the control group in the temporoparietal junction and in the inferior frontal gyrus. These areas of the brain are responsible for functions including the ability to put oneself in another person’s position and impulse control. In both groups, the researchers observed similar levels of activation in the dorsal anterior cingulate cortex and in the anterior insula – areas of the brain associated with affective processes.

The findings indicate that although both groups showed the same levels of emotional reactivity to unfair offers, the delinquent adolescents rejected these offers more often. In contrast to the control group, they did not take account of their opponent’s intention – or of whether their opponent had no alternative.

Marsh, A. A., Finger, E. C., Fowler, K. A., Adalio, C. J., Jurkowitz, I. N., Schechter, J. C., & … Blair, R. R. (2013). Empathic responsiveness in amygdala and anterior cingulate cortex in youths with psychopathic traits. Journal Of Child Psychology & Psychiatry, 54(8), 900-910. doi:10.1111/jcpp.12063


Why is Nursing Going into Advanced Practice?

By 1980, the American Nurses Association has (ANA) has declared that “specialization in nursing is now clearly established and that specialization is a mark of the advancement of the nursing profession”. Advanced nursing practice has reached increasing levels of acceptance and demand, interprofessional conflicts increased, with medicine perceiving Clinical Nurse Managers (CNMs) as a competitive threat. According to Hamric (1989), the role of the Clinical Nurse Specialists (CNS) “originated for the purpose of improving the quality of nursing care provided to patients” the historical development of psychiatric CNSs is the oldest and one of the most highly developed CNS specialties. This growth in the psychiatric nursing body of knowledge provided the support for psychiatric nurses to begin exploring new leadership roles in the care of mental health clients in both inpatient and outpatient settings. The impressive development of the psychiatric CNS role helped initiate the growth of other CNS specialty areas.

As the number of Nurse Practitioners (NPs) is increasing in response to the increasing demand, and the NP role has attracted considerable attention from professional groups and policy makers. The Obama Administration’s records on supporting the nursing workforce has stated the following  “…With implementation of the law, we have new opportunities to move to a health care system that focuses on increased access to primary care, improved care coordination and an emphasis on prevention and wellness—efforts nurses have focused on from the beginning. This is what the future of health care looks like, and it makes the work and expertise of America’s nurses more important than ever.”

Advanced nursing practice includes specialization but goes beyond it. The skills we learn in a Masters Program function synergistically to produce a whole that is greater than the sum of its parts. For the many reasons I chose to enroll in the Masters, is because I want to possess advanced health assessment, diagnostic, and clinical management skills that include pharmacological management. I want to feel more autonomous in my direct clinical practice. I have always been dedicated to coaching of patients, families and other health care providers, so, a masters in nursing will legitimize my professional attitude and practice. Another reason that is crucial for me is research, evidenced based practice is the golden frame for us; nurses, so research skills including, utilization, evaluation, and conduct are well taught and developed in the Masters program.

The common rule is that a Masters degree is inevitable for advanced practices nurses (APNs). The role of an APN, whether in primary care or acute care, makes a bigger difference because it challenges the status quo. The role is so expanded that includes, and is not limited to collaboration, leadership, management, and ethical decision-making. 

Substance-Related and Addictive Disorders: Alcohol Use Disorder – DSM-5


Alcohol use has never been a topic that lends itself naturally to sober, intellectual discourse. This is hardly surprising, really, given that what’s at stake is nothing less than our lives. Below I am going to mention co-morbidities associated with alcohol use disorder and the criteria of the DSM-5 for the diagnosis of Alcohol Use Disorder (AUD).

AUD is associated with psychotic disorders, bipolar disorders, depressive disorders, anxiety disorders, obsessive-compulsive disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders. The onset of these co-morbidities can be during intoxication and/or withdrawal.

It is worth noting that the word “addiction” is not mentioned in the DSM-5, however, it is in common usage in many countries and disciplines to describe severe problems related to compulsive and habitual use of substances.

The following are the diagnostic criteria for AUD:

A problematic patter of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in large amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
4. Craving, or a strong desire or urge to use alcohol.
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
8. Recurrent alcohol use in situations in which it is physically hazardous.
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
10. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of alcohol to achieve desired effect.
b. A markedly diminished effect with continued use of the same amount of alcohol.
11. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for alcohol.
b. Alcohol is taken to relieve or avoid withdrawal symptoms.

Stay sober and watch out for the people you love for any signs of alcohol addiction, and most importantly Never Ever Drink and Drive.

The Patient-Therapist Relationship: Secret of the Care


“…Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”  

 – Francis Peabody, MD

 Therapists (e.g. advanced practice psychiatric nurse, psychiatrist, and psychologist) should initially make sure that they know a patient’s name and that the patient knows the therapist’s name.  They should introduce themselves to other people who have come with the patient and should find out whether the patient wants another person present during the initial interview.

 Qualities of the caregiver:

  • Imperturbability: the ability to maintain extreme calm and steadiness
  • Presence of mind: self-control in emergency
  • Clear judgment: the ability to make an informed opinion that is free of ambiguity
  • Ability to endure frustration: the capacity to remain firm and deal with insecurity
  • Infinite patience: unlimited ability to hear pain
  • Charity towards others: to be generous especially to the needy and suffering
  • The search for absolute truth: investigate facts and pursue reality
  • Composure: calmness of mind and bearing
  • Bravery: the capacity to face or endure events with courage
  • Charity towards others: to be generous especially to the needy and suffering
  • The search for absolute truth: investigate facts and pursue reality
  • Composure: calmness of mind and bearing
  • Bravery: the capacity to face or endure events with courage


As much as physicians must legally and ethically respect patients’ confidentiality, it may be wholly or partially broken in patients’ situations. If a patient makes clear that he or she intends to harm someone, the therapist has a responsibility to notify the victim.


Emotions breed countermotions. For example, if the care giver is hostile, the patient becomes hostile; the care giver then becomes even angrier than before and the relationship deteriorates rapidly. Rising above such emotions involves being able to step back from the intense countertransferential reactions and explore why the patient is reacting in a self-defeating way. If the therapist can understand that the patient’s antagonism is in some ways defensive or self-protective and most likely reflects transferential fears of disrespect, abuse, and disappointment, the doctor may be less angry and more empathetic.


Empathy is a way of increasing rapport. An empathetic therapist may anticipate what is felt before it is spoken and can often help patients articulate what they are feeling. Patients sometimes say “How can you understand me if you haven’t gone through what I’m going through?” Clinical psychiatry, however, is predicated on the belief that it is not necessary to have other people’s literal experiences to understand them. The shared experience of being human is often sufficient.

While much early work on this subject was generated from a psychodynamic perspective, researchers from other orientations have since investigated this area. It has been found to predict treatment adherence (compliance) and concordance and outcome across a range of client/patient diagnoses and treatment settings. Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.

Most New Teachers Feel Unprepared to Help Students Deal With Mental Health Problems


  • Toronto district school board found stress and anxiety to be the most prevalent emotional issues among students
  • More than 100,000 students and 75 secondary school teachers
  • 92% of teachers reported that they had students struggling with mental issues
  • 97.4% of them agreed or strongly agreed that it was part of their job
  • 93.3% felt that their education training did not qualify them for dealing with mental health issues


Prevalence of Emotional Issues Among Students of Toronto 

                                                        Grade 7-8                                      Grade  9-12
Positive feelings
Feel good about yourself 80% 70%
Feel reasonably happy 78% 67%
Able to enjoy daily activities 76% 64%
Hopeful about the future 72% 62%
Like the way you look 67% 58%
Physical symptoms
Tired for no reason 58% 76%
Difficulty concentrating 56% 76%
Difficulty making decisions 56% 72%
Losing sleep bcz of worry 38% 57%
Doesnt overcomedifficulties 31% 47%
Feel like crying 21% 29%
Emotional challenges
Feel lonely 29% 43%
Feel down 32% 48%
Losing confidence 32% 48%
Under a lot of stress 40% 66%
Feel nervous/anxious 63% 72%


Action Plan:

1- Raising awareness about mental health issues (e. g., teen suicide, and bullying)

2- Providing resources to help students with mental health problems

3- Addressing the need of bachelor programs of student teachers to have a more thorough understanding of mental illness and its consequences



Sarah, B. (2013). Most new teachers feel unprepared to help students deal with mental health   problems: study. National Post. Retrieved from