By educating patients on early warning signs of hepatotoxicity, this rare but potentially fatal consequence could be detected early to allow appropriate intervention." (Wright and Vandenberg, 2007) it is extremely critical to understand the nature of psychiatric nursing in today's clinical environment.
IV. ROLE of NURSE PRACTITIONER in TRANSITION
Specifically stated in the work of Kathryn R. Puskar entitled; "The Nurse Practitioner Role in Psychiatric Nursing" published in the Online Journal of Issues in Nursing is: "Commercialization of psychiatric care is underway. Psychiatric inpatient admissions have decreased, admissions to general hospitals have decreased, while outpatient admissions are increasing. Academic centers are purchasing smaller hospitals as affiliates; satellite clinics and networks of services are being established. Physicians in solo practice are merging into group practices. New health care professional roles must be restructured and "cross trained" to maintain competitiveness by offering flexible, cost-saving effective care. This is the background environment in which the PPCNP is competing for a piece of the managed care dollar. The PPCNP provides a "Commodity or product" of quality psychiatric care combined with primary care emphasizing the psychotherapeutic skills. In her editorial in Archives in Psychiatric Nursing in December 1995, Krauss emphasized that in managing costs and care, psychiatric nursing must make mental health systems humane. She advocates that the core of psychiatric nurse's work is "therapeutic engagement with patients." The PPCNP is an example of this notion, a mesh of psychotherapeutic skills, of neurobiological knowledge, behavioral interventions, and physical assessment skills." (Puskar, 2007) Wess, Eglen and Guatam (2007) state: "Muscarinic acetylcholine receptors (mAChRs), M (1)-M (5), regulate the activity of numerous fundamental central and peripheral functions. The lack of small-molecule ligands that can block or activate specific mAChR subtypes with high selectivity has remained a major obstacle in defining the roles of the individual receptor subtypes and in the development of novel muscarinic drugs. Recently, phenotypic analysis of mutant mouse strains deficient in each of the five mAChR subtypes has led to a wealth of new information regarding the physiological roles of the individual receptor subtypes. Importantly, these studies have identified specific mAChR-regulated pathways as potentially novel targets for the treatment of various important disorders including Alzheimer's disease, schizophrenia, pain, obesity and diabetes." (2007)
V. ASSISTING SMI in DIABETES COMORBIDITY
Patients with diabetes are required to have much skill and information if they are to become 'self-regulating. In order to manage Type 2 diabetes effectively, one must understand...the basic pathological and physiological nature of diabetes, for example, what causes blood sugars to rise and fall as well as the effects of these high and low blood sugars." (Wess, Eglen and Guatam, 2007) Knowledge may also be needed for management of oral medicals or insulin..." (Wess, Eglen and Guatam, 2007) it is highlighted in this work that the social workers who are diabetes informed' are an especially important asset to diabetes educators and programs. The social worker "...can interject, affirm, and interpret relevant psychosocial factors during initial assessments and progress evaluations -- highlighting strengths, needs, family involvement and functioning, and the effects of patient, family, and group cultures on outcomes. They are invaluable as consultants or instructors to diabetic clients also dealing with cognitive deficits, learning disabilities, or chronic mental illnesses. Likewise, social workers are indispensable in designing and implementing education programs and materials tailored to meet the information and skill needs of people with learning challenges or educational deficits and especially young or elderly patients. In particular, social work practitioners are ideally suited to develop and teach the psychosocial component of a diabetes program that may include presentations on behavior modification, emotions, depression, stress and time management, and community resources. Social workers also can serve as resources to those lacking access to traditional diabetes programs, such as rural, homebound, uninsured, or underinsured populations or in medical settings with limited diabetes education resources." (Wess, Eglen and Guatam, 2007) the second tool is facilitation of the family-centered approach or 'family as the focus of intervention'. The family centered interventions are stated to include: "...Family-centered interventions may include soliciting and addressing family concerns, encouraging family attendance and participation at appointments, fostering shared responsibility and credit for treatment outcomes, incorporating family members' talents and health needs in the care plan, enlisting participation in classes, and selling everyone on the benefits of healthy habits for wellness and delaying or preventing the onset of diabetes. A large study is reported in the work of Koholokula, Schirmer, and Elting (2004) entitled: "Identifying and Prioritizing Diabetes Care Issues Among Mental Health Professionals of a Multi-Ethnic, State Psychiatric Hospital" relates the fact that those who have been diagnosed with schizophrenia and other severe mental illnesses are an increased risk for developing type 2 diabetes. This work reports an aggregated list identified by NGT groups of concerns for those with diabetes and who also are considered to be severely mentally ill. The technique used is the 'nominal group technique (NGT) which various mental health professional from the hospital. The goal of this study was the identification and prioritization of diabetes care issues among health professionals of a state psychiatric inpatient hospital using the nominal group technique (NGT) described by Delbecq et al." (Koholokula, Schirmer, and Elting, 2004) Several overlapping ideas are stated to be ranked in the top seven by at least two of the three NGT groups which include: (1) Lack of knowledge of diabetes and its care by both patients and staff; (2) Lack of proper training in diabetes care among staff; (3) Poor communication between hospital units and mental health disciplines; and (4) the need for multi-modal (e.g. diabetes support groups, focus on diabetes-specific behavioral skills, addressing attitude toward disease)
VI. MEDICAL NUTRITIONAL THERAPY (MNT)
To improve participation in outpatient programs, social workers can identify and address client barriers to keeping appointments, such as inadequate transportation, non-cooperative employers or family members, limited financial or child care resources, or even poor client motivation. Pairing newly diagnosed patients with "diabetic sponsors" -- individuals who are experienced and successful at managing their diabetes -- also may enhance attendance. Rather than relying on clients to come to clinics, social workers may need to bring the clinics to clients by organizing diabetic health fairs, outreach, or training programs in work settings, church facilities, or community centers. It is related that: "For people with Type 2 diabetes, Medical Nutritional Therapy (MNT) is often the "first-line therapy of choice" (Lipkin, 1999). The goal of MNT is to maintain near-normal glucose levels by matching dietary consumption with actual caloric (energy) needs, necessitating that the right foods in correct proportions be eaten at prescribed times for many MNT may include a secondary goal -- weight loss. Nutritional self-management or compliance with a prescribed diet can be handicapped by many of the same factors that impede self-care knowledge and skill mastery. In MNT, food assumes an almost medicinal quality, and many may resist altering long-held consumption patterns, inasmuch as food plays a part in their cultural heritage or serves as a source of pleasure; therefore, dietary changes are interpreted as loss of either function. For some patients, making these lifestyle changes may require assistance with concrete resources. As resource brokers, social workers can assess needs and link clients with community agencies for nutritional assistance, fitness training, additional diabetic education (professionals or material), medical care, health insurance, insulin and glucose monitoring supplies, prescription assistance, transportation, and counseling or support groups" (Lipkin, 1999)
VII. RESOURCE-BROKERING and COLLABORATION AMONG PROFESSIONALS
The social worker is also experienced in 'resource brokering' and as related by Lipkins (1999): "As a therapist, the social worker may practice independently or in conjunction with other professionals (such as psychiatrists and psychologists) to treat more serious mental health issues inhibiting the management of diabetes. In this role a social work practitioner may screen and treat illnesses with high rates of comorbidity among diabetes patients, such as major depression or eating and anxiety disorders. The social worker also may ensure the management of preexisting chronic mental illnesses like schizophrenia, bipolar disorder, and alcohol or substance abuse." (Lipkin, 1999) the social worker also has the capacity to: "...coordinate a comprehensive assessment, treatment plan, and intervention, striving for an optimal level of collaboration among professionals, patients, and families. Financially, social work case management can effectively and efficiently use community resources, creating an optimal environment that promotes glycemic control to delay complications and reduce hospitalizations."