Introduction of Mental Health Nursing

1
Introduction of Mental Health Nursing
2
Definition of Mental Health Nursing

• A specialty within the nursing profession that
  focuses primarily on the use of therapeutic
  interpersonal interactions and biologic and
  interpersonal interventions with clients.
• Mental health nursing focuses on human aspects
  and responses to illness and is therefore part of
  all areas of nursing.

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Four Core Mental Health Practice Areas

• Psychiatric nursing
• Psychiatry
• Psychology
• Social work

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Professional attributes of psychiatric nurses
include

• Promotion of mental health
• Prevention and treatment of mental disorders
• Rehabilitation after the disorder

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Historical Overview of Psychiatry
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• Prior to the 19th century, practitioners would
  say that mentally ill patients had idiocy most
  treatments were cruel and inhumane
• Police took people to madhouses a private
  boarding home without legal or therapeutic
  guidelines to govern care
• At the end of the 19th century, private and
  public psychiatric hospitalizations began
  providing mostly custodial care
• The 1950s saw the advent of new meds that
  revolutionalized the treatment and decreased the
  number of hospitalized patients

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1960s- Deinstitutionalization

• In 1963, President Kennedy decided that you
  couldnt institutionalize.
• The goal of deinstitutionalization was to
  replace the cold mercy of custodial isolation
  with the open warmth of community concern and
  capability.
• This shifted the emphasis of mental health care
  from hospitals to community mental health centers.

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1970s-1990s

• Discovery of neurobiological factors influencing
  mental disease
• The decade of the 1990s was named by Congress as
  the Decade of the Brain
• Proliferation of newer biochemical therapies
  effective in treating mental disorders
• Expanding scientific technology-MRI, CT, and PET
  scans

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The Millennium and Beyond

• Shorter hospital stays secondary to economic
  pressures from managed care
• Care today emphasizes community-linked care
• Development of new indications for the
  antidepressant medications
• Continued investigation of the brain and
  neurotransmitters

10
Concept of Nature vs Nurture

• Psych d/os formerly were thought to rise from
  some disruption in early life experiences
• Rigid toilet training led to unrelenting thoughts
  and behaviors like repeated hand washing (OCD)
• Later a new wave of theories of causation then
  emerged
• Biologic and genetic factors accounted for the sx
  of psychiatric illness, i.e., people were manic
  depressive not because of poor parenting or
  difficulty in childhood but because of their
  genetic makeup

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Concept of Nature vs Nurture

• We now know that neither of these extreme
  positions fully explain the complexity of the
  brain
• It is much more probable that psychiatric
  disorders result from some combination of the 2
  theories

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The Nurse-Client Relationship An Art and a
Science

• First described by Hildegard Peplau in her text
  Interpersonal Relations in Nursing (1952)

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The Art

• The art of caring is the basis for PMHN and is
  embodied in the nurse-client relationship.
• The nurse-client relationship is often referred
  to as a therapeutic alliance which is used to
  effect change, promote growth, and heal mental
  and emotional wounds.

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Core Characteristics of a Successful Therapist

• Empathy
• Warmth
• Genuineness
• Respect
• Concreteness
• Immediacy
• Confrontation
• Self-Disclosure

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The Science
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I. Principles of the Nurse-Client
Relationship
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Principles of the Nurse-Client
Relationship

• The relationship is therapeutic rather than
  social
• The focus remains on the clients issues rather
  than on the nurses or other issues
• The relationship is purposeful and goal directed
• It is objective versus subjective in quality
• It is time limited versus open ended

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Therapeutic vs Social

• A therapeutic relationship is formed to
• help clients solve problems
• make decisions
• achieve growth
• learn coping strategies
• let go of unwanted behaviors
• reinforce self-worth
• examine relationships

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Therapeutic vs Social

• The meetings between nurse and client are not for
  mutual satisfaction.
• The nurse can be friendly with the client, but is
  not there to be the clients friend.
• The majority of the interaction is focused and
  therapeutic.

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Client Focus

• During an interaction, a client may redirect the
  focus away from self by changing the subject,
  talking about the weather, etc.
• The nurse needs to recognize this as a divergent
  tactic, confront this behavior, and refocus the
  client.

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Goal Direction

• The primary purpose of a therapeutic relationship
  is helping clients to meet adaptive goals.
• Nurse and client work together to identify
  problematic areas in clients life
• Once goals are established, the nurse and client
  agree to work toward those goals.

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Objective vs Subjective

• Nurses can be therapeutic only if they remain
  objective.
• Objectivity refers to remaining free from bias,
  prejudice, and personal identification in
  interaction with the client and being able to
  process information based on facts.
• Subjectivity refers to emphasis on ones own
  feelings, attitudes, and opinions when
  interacting with the client.

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Time-Limited Interactions

• Time of meetings
• Number of meetings that will take place
• Provides structure
• Lets client know that relationship will end

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Stages of the Nurse-Client Relationship

• Preorientation phase
• Orientation phase
• Working phase
• Termination phase

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Preorientation Phase

• Takes place prior to meeting with the client
• 1st gather data about the client, his or her
  condition, and the present situation
• Nurse then examines his or her thoughts,
  feelings, perceptions, and attitudes about this
  particular client

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Orientation Phase

• The nurse-client become acquainted build trust
  and rapport
• A contract is established
• Includes time and place for the meeting, as well
  as the purpose of the meetings
• Dependability is imperative for both the nurse
  and the client
• Client strengths, limitations, and problem areas
  are identified
• Outcome criteria and a plan of care are
  established

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Working Phase

• Orientation phase ends and working phase begins
  when the client takes responsibility for his or
  her own behavior change
• Client shows commitment to working on issues that
  have caused a life disruption
• Clients needs are prioritized- safety and health
  come first
• RN assists the client to change problematic
  behaviors in a safe environment

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Termination Phase

• Relationship comes to a close
• This phase begins in the orientation phase when
  meeting times are established- lets the client
  know that the relationship will come to an end
• Avoids confusing the client who may be unable to
  recognized boundaries in a relationship
• Termination occurs when the client has improved
  or has been discharged

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II. Nursing Scope of Practice
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Nursing Scope of Practice

• Standards of care and practice for psychiatric
  mental health nurses were developed by the
  American Nurses Association and continue to
  describe functions.
• The areas of concern for mental health nurse
  include a wide range of actual and potential
  mental health problems.

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Standards of care

• The standards of care are organized around
  nursing process and include six component
  assessment, diagnosis, outcome identification,
  planning implementation, and evaluation.

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Mental health practice levels

• Basic
• Advanced
• These levels differentiated by educational
  preparation, complexity of practice, and
  performance of nursing function

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Basic Practice Level

• At the basic practice level, nurses can intervene
  in the following ways
• 1. Counseling
• described by the ANA as including
  interviewing and communication techniques,
  problem solving, crisis intervention, stress
  management, and behavior modifications

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Basic Practice Level (cont.)

• 2. Milieu Therapy
• The environment is used as a therapeutic tool to
  modify behaviors, teach skills, and encourage
  communication between the client and others.
• 3. Self-Care Activities
• Encouraging independence within a clients
  ability and capacity urges clients to take
  responsibility for their care thus improving
  their self esteem.

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Basic Practice Level (cont.)

• Psychobiologic Interventions
• Knowledge of medications used in the
  psychiatric setting
• Health Teaching
• Health Promotion and Health Maintenance
• Case Management
• Coordinates comprehensive health services
  and ensures continuity of care

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Advanced Practice Level

• The following interventions may be employed by
  clinical specialists and nurse practitioners who
  are certified in advanced psychiatric mental
  health nursing
• Psychotherapy
• Prescription of Pharmacologic Agents
• Consultation
• Education

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III. Mental Health and Mental
Disorder
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Defining and Classifying Mental Health and Mental
Disorder

• The ANA defines mental health as a state of
  well-being in which individuals function well in
  society and are generally satisfied with their
  lives.
• Results in socially acceptable behavior and the
  ability to respond productively and appropriately
  in the environment

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Defining and Classifying Mental Health and Mental
Disorder

• Mental disorder is a disturbance in an
  individuals thinking, emotions, behaviors, and
  physiology.
• Leads to problems with behavior, relationships,
  and functioning.

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Mental Illness and Mental Health Continuum

• Mild?joys, sorrows, and anxiety levels that aid
  in the work of living
• Mild-Moderate?psychophysiologic factors affecting
  medical conditions
• Moderate-Severe?anxiety d/os, dissociative d/os,
  somatoform d/os, personality d/os, and eating
  d/os
• Severe-Psychosis?depressive d/os, bipolar d/os,
  schizophrenic d/os, and cognitive d/os

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IV. Psychiatric Diagnoses
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Diagnoses in mental health

• Precise descriptions and classifications of
  mental disorders
• Categorical vs dimensional diagnosis
• 1. Categoric
• Represents a specific set of symptoms
• Allows for easier communication among mental
  health care providers
• Prognosis
• (ex, DSM)
• 2. Dimensional
• Describe of individual response and behavior to
  illness and provide direction of treatment
• (ex, NANDA)

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Diagnostic Nomenclatures

• A nomenclature of psychiatric diagnoses developed
  by the APA is widely accepted in the US as the
  official diagnostic criteria in clinical,
  research, and educational settings.
• The diagnoses are published in the Diagnostic and
  Statistical Manual of Mental Disorders, 4th
  edition. (DSM IV)

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DSM IV

• A multiaxial classification scheme that allows
  for the interrelation of biological,
  psychological, and social aspects of an
  individuals condition.
• Axis I clinical disorders (the psychiatric
  diagnosis)
• Axis II personality disorders and mental
  retardation
• Axis III general medical conditions
• Axis IV psychosocial and environmental problems
• Axis V global assessment of functioning (GAF)-
  rates the overall psychological functioning of
  the client on a scale of 0-100.

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NANDA

• Nomenclature of nursing diagnoses
• Many applicable in the psychiatric setting

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V. The Nursing Process
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The Nursing Process

• A scientific, problem-solving method that assists
  nurses in total client care.
• Consists of 6 steps
• Assessment
• Diagnosis
• Outcome Identification
• Planning
• Implementation
• Evaluation

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VI. Therapeutic Treatment Modalities
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Therapeutic Rx Modalities

• Traditional inpatient hospitalization has been
  replaced with an entire range of care options
• Rx options include
• Inpatient hospitals
• Outpatient day treatment programs
• Clinics
• Home care
• Community centers
• Crisis centers
• Place of employment/school

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Therapeutic Rx Modalities (cont.)

• Types of Therapies
• Interactive therapies- includes all of those in
  which the client has interpersonal contact with 1
  or more therapists and includes interaction with
  other clients
• Biologic therapies- includes the use of
  medications and ECT

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VII. Current Epidemiology and Research
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Current Epidemiology and Research

• Approx 28 of Americans over the age of 18 suffer
  from a mental or addictive disorder in a 1 year
  period
• See page 11 in the text for prevalence of psych
  d/os in the US

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VIII. Prevention of Disorders
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Prevention of Disorders

• Gerald Caplan (1964) proposed a model for
  preventive care of persons with mental disorders.
• Model proposes 3 levels of preventions
• Primary
• Secondary
• Tertiary

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Primary Prevention

• Focuses on reduction of the incidence of mental
  disorders within the community
• Emphasizes health promotion and prevention
• Example Teaching stress reduction techniques to
  any population

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Secondary Prevention

• Directed toward reducing the prevalence of mental
  disorders through early identification and early
  Rx of those problems
• Example assessing sx of depression such as sleep
  disturbances, appetite changes, diminished
  interest during routine interview with client if
  problem identified- treat

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Tertiary Prevention

• Has the dual focus of reducing residual effects
  of the disorder and rehabilitating the individual
  who experienced the mental disorder
• Example Social skills training to a schizophrenic

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IX. Roles of the Mental Health Team
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Roles of the Mental Health Team

• Psychiatric Nurse
• Has the most widely focused position description
  of any of the member roles
• Interacts with clients in individual and group
  settings
• Manages client care
• Administers and monitors meds
• Teaches both clients and families
• Acts as a client advocate

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Roles of the Mental Health Team

• Psychiatric Social Worker
• Graduate level position
• Work with clients on an individual basis
• Conduct group therapy sessions
• Act as liaisons with the community to place
  clients after discharge

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Roles of the Mental Health Team

• Psychiatrist
• Licensed medical physician who specializes in
  psychiatry
• Prescribe and monitor meds
• Admit clients into acute care settings
• Administer ECT
• Conduct individual and family therapy

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Roles of the Mental Health Team

• Psychologist
• Licensed individual with a doctoral degree in
  psychology
• Assess and treat psychologic and psychosocial
  problems of individuals, families, or groups
• Do not prescribe or administer medications
• Administer psychometric tests that aid in the
  diagnosis of disorders

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Roles of the Mental Health Team

• Marriage, Family, Child Counselor
• Licensed individuals who frequently work in
  private practice
• Prepared to work with individuals, couples,
  families, and groups
• Emphasize the interpersonal aspects of achieving
  and maintaining relationships

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Roles of the Mental Health Team

• Case managers
• Facilitate the delivery individualized,
  coordinated care in cost-effective ways
• Need to know the various types of hospitalization
  and outpatient care settings, the coverage
  offered by different payers, and the impact of
  state and federal legislation

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X. Trends and Issues of the Future
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Trends and Issues of the Future

• Dominant issue in mental health is managed care
• The outcome of managed care for clients and
  families with mental disorders are reported to be
  ineffective
• Because of managed care and lack of funding,
  clients are often discharged before they are
  ready to leave the hospital

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References

• Hania Dawani (2010). Foundations of Psychiatric
  Mental Health Nursing. Presentation in
  Philadelphia University.
• Boyd, Mary Ann (2005). Psychiatric nursing
  Contemporary Practice. Philadelphia Lippincott
  Williams Wilkins.