Psychiatric-Mental Health Nursing

Unit 1: Current Theories & Practice

by Sheila L. Videbeck, PhD, RN 8th Edition

Gil Benedict C. Llamelo, RN, MANc

Medical- Psychiatry RN, DOH-National Center for Mental Health
Instructor, Bulacan State University – College of Nursing
Health

“Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or
infirmity”

- World Health Organization

 Chapter 1:
Foundations of Psychiatric-Mental Health Nursing

In most cases, mental health is a state of

emotional, psychological and social wellness
 Mental Health & Mental Illness evidenced by satisfying interpersonal
relationships, effective behavior and coping,
 Difficult to define positive self-concept and emotional stability.
 No single, universal definition
 Many components influenced by Factors
(Individual, Interpersonal, Social/Culture)
 Dynamic, ever-changing state
 Influencing Factors:
Individual:
 Biologic make up
 Autonomy & independence
 Self-esteem
 Capacity for growth
 Vitality
 Ability to find meaning in
life
 Emotional resilience
 Sense of belongingness
 Reality orientation
 Coping or stress
management abilities
Interpersonal:
 Relationship
 Effective communication
 Ability to help others
 Intimacy
 Balance of separateness
and connectedness
Social/Cultural:
 Environmental
 Sense of community
access/ adequate
resources
 Intolerance of violence
 Support of diversity
 Master of the environment
 Positive,yet realistic view
of one’s world
 Mental Illness:
 Includes disorders that affect mood, behavior and thinking (depression, schizophrenia, anxiety disorders and
addictive disorders)
 Often cause significant distress or impaired functioning or both
 Individuals experience dissatisfaction with self, relationships and ineffective coping
 Daily life can seem overwhelming or unbearable
 May believe that their situation is hopeless
 Factors contributing to mental illness can also be viewed within INDIVIDUAL, INTERPERSONAL AND
SOCIAL/CULTURAL CATEGORIES.
 Diagnostic and Statistical Manual of Mental Disorders
 A taxonomy published by the
American Psychiatric Association and
revised as needed (2013, 5th Edition)
 DSM-5 describe all mental disorders,
outlining specific criteria for each
based on clinical experience and
research
DSM-5 has 3 purposes:
 To provide a standardized
nomenclature and language for
all mental health professionals
 To present defining
characteristics or symptoms
that differentiate specific
diagnosed
 To assist in identifying the
underlying cause of disorders
Historical Perspectives:

Ancient times
 Sickness as displeasure of gods; punishment for sins; view as
demonic or divine
 Aristotle and imbalances of the four humors (blood, water, yellow
and black bile); balance restoration via bloodletting, starving,
purging (382- 322 BC) until 19th Century
 Early Christians’ view as possession by demons (1-1000 AD)
 England, during the Renaissance (1300-1600), people with mental
illness were distinguished from criminals; in the US, mentally ill
were considered evil or possessed they were punished (witch
hunts, burned at stakes)
 On 1547, Hospital of St. Mary of Bethlehem was officially declared a
hospital for the insane
Historical Perspectives:

Period of Enlightenment (1790s)

 Creation of asylums; moral treatment ( Philippe Finel and William Tuke)
 Dorothea Dix of US (1802), opened 32 state hospitals that offered asylum to the suffering
-she believed that society was obligated to those who were mentally ill
 Sigmund Freud: scientific study, treatment of mental illness (186-1939)
Historical Perspectives:

 Psychopharmacology (1950s): development of psychotropic drugs

Thorazine and Lithium were the first drugs to be developed; 10 years after, MAOI’s, TCA,
Anxiolytics, Antipsychotics (Haloperidol)
 Community mental health movement
 Deinstitutionalization
- Community Health Centers Construction Act (1963)
- Deliberate shift from institutional care in state hospitals to community facilities
 Legislation for disability income (Supplemental Security Income or SSI and Social Security
Disability Income or SSDI)
 Changes in commitment laws ( difficult for treatment against the pt’s will)
Mental Illness in the 21st Century ( current state)

 More than 26% of Americans 18 and older have diagnosable mental disorder (NIMH, 2008)
 15 million adults, 4 million children and adolescents with impaired daily activities
 Economic burden exceeds that by all types of cancer
 Leading cause of disability in United States Canada for those years of age1 in 4 adults and 1 in
5 children and adolescents getting care needed but only 1 in 4 adults and 1 in 5 children and
adolescents requiring mental health sevices get the care they need.
Mental Illness in the 21st Century (Issues and concerns)

Deinstitutionalization
 Shorter hospital stays, decompensation,
rehospitalization, dual diagnoses
Positive effect: Reduced the use of hospital beds by 80%
Negative effect: Increase in admission by 90%
“Revolving door effect”
Mental Illness in the 21st Century (Issues and
concerns)

 Homelessness (⅓ estimated to have serious mental illness; over ½ with substance abuse
problems)
 Lack of adequate community resources
 ACCESS to address needs of full- or part- time homeless persons with mental illness
 Homelessness worsens psych problems for many people with mental illness who end up on
the streets, contributing to a vicious cycle
Objectives for the Future

Healthy People 2020 Mental Health Objectives

 Reduce the suicide rate
 Reduce suicide
 Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to
control their weight
 Reduce the proportion of persons who experience major depressive episode
 Increase the proportion of primary care facilities that provide mental health treatment onsite or by
paid referral
 Increase the proportion of juvenile residential facilities that screen admissions for mental health
problems.
 Increase the proportion of persons with serious mental illness who are employed
 Increase the proportion of adults with mental health disorders who receive treatment
Objectives for the Future

Healthy People 2020 Mental Health Objectives

o Increase the proportions of persons with co-occurring substance abuse and mental disorders who
receive treatment for both disorders
o Increase depression screening by primary care providers
o Increase the number of homeless adults with mental health problems who receive mental health
services.
Objectives for the Future

 These objectives were originally developed as Healthy People 2000, were revised in Janury 2000 and
again in January 2010 to increase the number of people who are identified, diagnosed, treated and
helped to live healthier lives.
 A framework has been developed for Healthy People 2030
 Development of community support programs:

Community-Based Care
 Lack of appropriate number of community mental
Consequences:
health centers to provide services  Homelessness
 Development of community support programs  Psychiatric Boarding
 Arrest
 Availability, quality of services highly variable
 Incarceration
 Inaccurate anticipation of extent of people’s needs  Victimization
 Despite flaws, positive aspects making them  Suicidality
 Familiar Violence
preferable for treatment
 Danger to other
 Cost Containment and Managed Care:
 (1970): Managed care system
-concept designed to purposely control the balance between the quality of care provided and the
cost of that care.
-people receive care based on need not on request
 (1990s); Development of utilization review firms/managed care organizations
- control the expenditure of insurance funds by requiring providers to seek approval before the
delivery of care
 Case management
-management of care on a case-by-case basis, represented an effort to provide necessary services
while containing the cost.
 Separation of mental health care from physical care for insurance coverage
- psychiatric care is costly because of the long –term nature of the disorders
Cultural Considerations

 Nurses must be prepared to care for the culturally diverse population; preparation includes being aware of
cultural difference that influence mental health

Culturally diverse population Influenced Mental Health

Cultural differences Affects Treatment of Mental Illness.
Changes in family structure
Psychiatric Nursing Practice

Linda Richards
 1873, Improved nursing care in psychiatric
hospitals
 Organized educational programs in a state mental
hospitals
 “First American Psychiatric Nurse”
“the mentally sick should be at least as well cared for
as the physically sick”
Psychiatric Nursing Practice

 McLean Hospital, Belmont MA: site of first training for nurses to work with persons with
mental illness
 Expansion of role with development of somatic therapies requiring nurses to use their
medical-surgical skills extensively:
Insulin Shock Therapy (1935)
Pscyhosurgery (1936)
Electroconvulsive Therapy (1937)
Psychiatric Nursing Practice

 First psychiatric nursing textbook (Nursing Mental Diseases) published in 1920

 Johns Hopkins: first school of nursing to include psychiatric nursing course (1913)
 National League for Nursing (1950) requiring schools to include psychiatric nursing experience
Psychiatric Nursing Practice

Hildegard Peplau June Mellow

 Interpersonal Relations in Nursing (1952)  Nursing Therapy (1986)
 Interpersonal Technique: The Cruz of Psychiatric  focus on client’s psychosocial needs,
Nursing strengths
 Interpersonal Relations Theory
- therapeutic nurse-client relationship with its
phases and tasks and wrote extensively about anxiety
(foundation for current practice)
 ANA Standards of Care

Counselling Milieu Therapy Self-care activities Psychobiologic

 Interventions &  Maintain therapeutic  Encourage Independence Interventions
Communication Tech environment  Increase self-esteem  Administer Medications
 Problem-Solving  Teach Skills  Improve function and  Teach
 Crisis Intervention  Encourage communications health  Observe
 Stress Management between clients and others
 Behavior Modification  Promote growth through role
modeling Advanced-level Functions
 Psychotherapy
 Prescriptive authority for drugs
Health Teaching  Consultation and liason
Case Management  Evaluation
Health Promotion and  Program development and management
Maintenance  Clinical Supervison
Psychiatric-Mental Health Nursing Phenomena of
Concern

 Promotion of optimal mental and physical health and well-being and prevention of mental illness
 Impaired ability to function related to psychiatric, emotional and physiologic distress
 Alterations in thinking, perceiving and communication because of psychiatric disorders or mental health
problems
 Behaviors and mental states that indicate potential danger to self or others
 Emotional stress related to illness, pain, disability and loss
 Symptoms mgt, side effects or toxicities associated with self-administered drugs, psychopharmacologic
interventions and other treatment modalities
 The barriers to treatment efficacy and recovery posed by alcohol and substance abuse and dependence
 Self-concept and body image changes, developmental issues, life process changes and end-of –life issues
Psychiatric-Mental Health Nursing Phenomena
of Concern

 Physical symptoms that occur along with altered physiologic status

 Interpersonal, organization, sociocultural, spiritual or environmental circumstances or events that have an
effect on the mental and emotional well-being of the invidual and family or community
 Elements of recovery, including the ability to maintain housing, employment and social support that help
individuals reengage in seeking meaningful lives
 Societal factors such as violence, poverty and substance abuse
 Student Concerns
 What if I say wrong thing?
 No one magic phrase can solve a client’s
problems; likewise, no single statement can
significantly worsen them. Listening carefully,
showing genuine interest and caring about the
client are extremely important. A nurse who
possess these elements but say something that
sounds out of place can simply restate it by
saying “that didn’t come out right, what I meant
was…..”
 What will I be doing?
 In the mental health setting, many familiar tasks
and responsibilities are minimal. Physical care
skills or diagnostic test and procedures are fewer
than those conducted in a busy MS setting. The
idea of “just talking to people” may make the
student feel as though he or she is not really
doing anything. The student must deal with his
or her own anxiety about approaching a stranger
to talk about sensitive and personal issues.
Development of the therapeutic nurse-client
relations and trust takes time and patience.
 Student Concerns
 What if no one will talk to me?
- Many people in emotional distress welcome
the opportunity to have someone listen to them
and show a genuine interest in their situation.
Being available and willing to listen is often all
it takes to begin a significant interaction with
someone.
 Am I prying when I ask personal
- You may feel awkward. It is important to
remember that questions involving personal
matters should not be the first thing a student
nursing says to the client. Therapeutic
Communication helps
Student Concerns

 How will I handle bizarre or inappropriate behavior?

 Ask your CI and staff nurse for assistance
o What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?
 Some clients have difficulty recognizing or maintaining interpersonal boundaries
 Clarify the boundaries of the professional relationship
o Is my physical safety in jeopardy?
-Actually clients hurts themselves more often than they harm others.
-staff will respond, SN should not become involved
-sit in open area rather than in a closed room, provide plenty of space for the clients, or CI and staff can be present
Student Concerns

 What if I encounter someone I know being treated on the unit?

 Maintain confidentiality
 Notify your instructor/ staff
o What if I notice I share similar problems or backgrounds with clients?
-May notice the same family dynamics, life events
-comparison is inevitable but always remember that coping skills is the key part of mental health and not the
same for all.
Self-Awareness

 Process by which the nurse gains recognition of his or her own feelings, beliefs and attitudes and values -
primary focus of nursing
 Accept differences as a part of treatment
Example: Abortion
 Accomplish through reflection
 Student nurse needs to discover him or herself and what he or she believes before trying to help others with
different views.