Chapter 1:

Foundations of Psychiatric–
Mental Health Nursing
Mental Health

v Difficult to define
v No single, universal definition
v Many components influenced by wide variety of factors
v Dynamic, ever-changing state
v Influencing factors:
o Individual (personal)
o Interpersonal (relationship)
o Social/cultural (environmental)

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Mental Illness #1

v Includes disorders that affect:

o Mood
o Behavior
o Thinking
v Mental disorders often cause significant distress and/or
impaired functioning.

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Mental Illness #2
v Factors contributing to mental illness include (but are not
limited to):
o Individual:
§ Biologic makeup
§ Intolerable or unrealistic worries or fears

o Interpersonal:
§ Ineffective communication
§ Inadequate social support

o Social/cultural:
§ Unwarranted negative view of the world
§ Discrimination (stigma, racism, classism, etc.)

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Diagnostic and Statistical Manual of
Mental Disorders

v DSM-5: Taxonomy published by the American Psychiatric

Association
v Purposes:
o Standardize nomenclature and language
o Present defining characteristics or symptoms
o Assist in identifying the underlying causes of
disorders

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DSM Classification

v Allows the practitioner to identify all factors that relate to

a client’s condition:
o Major psychiatric disorders
o Medical conditions
o Psychosocial and environmental problems

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1. Question #1

Is the following statement true or false?

v The definition of mental health is standardized and
universally accepted.

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1. Answer to Question #1

False
v Rationale: There is no single, universal definition of
mental health, which has many components and is
influenced by myriad factors.

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Historical Perspectives #1

v Ancient times
o Sickness as displeasure of gods; punishment for
sins; viewed as demonic or divine
o Aristotle and imbalances of the four humors (blood,
water, yellow and black bile); balance restoration via
bloodletting, starving, and purging
o Early Christians’ view as possession by demons
o Distinguished from demons during the Renaissance

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1. Historical Perspectives #2

v Period of enlightenment (1790s)

o Creation of asylums; moral treatment
o Dorothea Dix
v Sigmund Freud: scientific study, treatment of mental
illness

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2. Historical Perspectives #3

v Psychopharmacology (1950s): development of

psychotropic drugs
v Community mental health movement
o Deinstitutionalization
o Legislation for disability income
o Changes in commitment laws

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Mental Illness and the 21st Century #1

v Current state:
o 44.7 million people in the United States have a
mental illness, though only 19.2 million received
treatment within the past year (NIH, 2018).
o 15 million adults and 4 million children and
adolescents with impaired daily activities
o Economic burden exceeds that of all types of cancer.

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1. Mental Illness and the 21st Century #2

v Current state—(cont.):
o Leading cause of disability in the United States and
Canada for those 15 to 44 years of age
o Increasing number of both adults and
children/adolescents are being treated for mental
illness; yet, only 1 in 4 adults and 1 in 5 children and
adolescents are treated.
o Treatment still lagging in homeless and those with
substance abuse problems.

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2. Mental Illness and the 21st Century #3

v Issues and concerns:

o “Revolving door” effect due to deinstitutionalization
§ Often “boarded” in ED while awaiting inpatient beds
o Shorter hospital stays, decompensation,
rehospitalization, and dual problem of both mental
illness and substance abuse

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3. Mental Illness and the 21st Century #4

v Issues and concerns (cont.):

o Homelessness (33% estimated to have serious
mental illness associated with substance abuse)
o 30% of the chronically homeless have a psychiatric
illness.
o Lack of adequate community resources

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2. Question #1

v Which statement best reflects the current state of mental

health and mental illness?
A. Mental health care costs exceed the costs for cancer
care.
B. Most adults and children receive adequate mental
health care.
C. Community resources for the homeless with mental
illness are adequate.
D. Deinstitutionalization has reduced the revolving door
effect.

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2. Answer to Question #2

A. Mental health care costs exceed the costs for cancer

care.
v Rationale: The economic burden of mental illness
exceeds that for all types of cancer care.
o Only 1 in 4 adults and 1 in 5 children and
adolescents receive the necessary mental health
care. Community resources for homeless clients with
mental illness are inadequate. Deinstitutionalization
has led to the “revolving door” effect.

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Objectives for the Future

v Healthy People 2020 objectives:

o Increase the number of people identified, diagnosed,
treated, and helped to live healthier lives
o Decrease rates of suicide and homelessness
o Increase employment for those with serious mental
illness
o Provide more services for incarcerated persons with
mental health problems

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Community-Based Care

v Lack of appropriate number of community mental health

centers to provide services
v Development of community support programs
o Availability, quality of services highly variable
o Inaccurate anticipation of extent of people’s needs
o Despite flaws, positive aspects make them preferable
for treatment

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Cost Containment and Managed Care #1

v Managed care movement (early 1970s)

v Development of utilization review firms/managed care
organizations (1990s); case management
v Separation of mental health care from physical care for
insurance coverage

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Cost Containment and Managed Care #2

v Mental health care management through privately owned

behavioral health care firms
o If no private insurance, reliance on counties of
residence for payment
v HCFA: Medicare and Medicaid
v Mental health parity, insurance coverage

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Cultural Considerations

v Culturally diverse population

v Cultural differences influencing mental health and
treatment of mental illness (see Chapter 7)
v Changes in family structure

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3. Question #3

Is the following statement true or false?

v Community-based programs are preferable for treating
many people with mental illness.

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3. Answer to Question #3

True
v Rationale: Although there are flaws in the system,
community-based programs have positive aspects that
make them preferable for treating many people with
mental illness.

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Psychiatric Nursing Practice #1

v Linda Richards: first American psychiatric nurse

v McLean Hospital, Belmont, MA: site of first training for
nurses to work with persons with mental illness
v Expansion of role with development of somatic therapies

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1. Psychiatric Nursing Practice #2

v First psychiatric nursing textbook (Nursing Mental

Diseases) was published in 1920.
v Johns Hopkins: first school of nursing to include
psychiatric nursing course (1913)
v National League for Nursing (1950) requiring schools to
include an experience in psychiatric nursing

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2. Psychiatric Nursing Practice #3

v H. Peplau: therapeutic nurse–client relationship;

interpersonal dimension (foundation for current practice)
v J. Mellow: focus on client’s psychosocial needs and
strengths
v American Nurses Association and standards of care
v Psychiatric–Mental Health Nursing Phenomena of Concern
(see Box 1.2)

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3. Psychiatric Nursing Practice #4

v Basic-level functions v Advanced-level functions

o Counseling o Psychotherapy
o Milieu therapy o Prescriptive authority
for drugs
o Self-care activities
o Consultation and
o Psychobiologic liaison
interventions
o Evaluation
o Health teaching
o Program
o Case management development,
o Health promotion and management
maintenance o Clinical supervision
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Student Concerns and Psychiatric–Mental
Health Clinical Experience

v Saying the wrong thing

v Knowing what to do
v Being rejected or refusal to talk
v Asking personal questions
v Handling bizarre, inappropriate, or sexually aggressive
behavior
v Physical safety
v Encountering someone known
v Dealing with similar problems or backgrounds

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Self-Awareness Issues

v Gaining recognition of one’s own feelings, beliefs, and

attitudes
v Everyone has unique and different values, ideas, and
beliefs.
v Possible conflict between personal values/beliefs, those
of client
v Need to accept differences; view each client as
worthwhile regardless of opinions or lifestyle
v Self-awareness through reflection

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4. Question #4

Is the following statement true or false?

v The National League for Nursing required schools to
include a psychiatric nursing experience before the first
nursing school included a psychiatric nursing course in its
curriculum.

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4. Answer to Question #4

False
v Rationale: Johns Hopkins was the first school of nursing
to include a course in psychiatric nursing in its
curriculum; this was done in 1913. It was not until 1950
that the National League for Nursing required schools to
include an experience in psychiatric nursing.

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