Experimental Design Concepts

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• Mental Health Nursing, Unit Two covers chapters 4,5,6,7,8,9 and 10

Chapter Four: Finding Treatment

• It is more difficult to find mental health treatment than it is for physical ailments
• Primary care providers can be a starting point for mental health treatment
• Primary care providers tend to care for people without serious concerns or complications
• Primary care providers frequently refer individuals to specialists for mental health care

Specialty Care Providers

• APRNs, Clinical nurse specialists, psychiatrists, psychologists, social workers, and therapists exist
• Specialty care providers give medications, psychotherapy, group therapy, and other treatments
• Patient-centered medical homes and primary care homes, Community Mental Health Centers, and Psychiatric Home care are resources
• Assertive Community Treatment, In-patient, and outpatient care, and community prevention programs are different forms of treatment

Biopsychosocial Assessment

• The patient's abilities to cope in their environment are assessed
• The best treatment facility option of inpatient or outpatient is assessed
• Housing situation, source of income, family/support system, and substance abuse history are considered
• Physical health and cultural considerations are taken into account
• Treatment goals and interventions, case management, maintenance of current treatment, and teamwork and collaboration are implemented

Emergency Care

• Comprehensive Emergency Service Model, Hospital Based Consultant Model, and Mobile Crisis Teams provide emergency care
• Observation Units exist for mental health services

Inpatient Care

• 13% of all ER visits relate to mental health
• The US experiences significant wait times to find mental health placements
• Admission criteria includes imminent danger of harming self or others, or inability to meet basic needs/self-protection
• There are two types of admission: voluntary and involuntary
• Patients retain their rights when admitted to inpatient care
• "Cheeking" when patients hold meds in their cheek is a consideration when giving medication

Teamwork

• The team works to provide a therapeutic milieu and manage behavior crises
• A plan must be made for behavior management and safety
• Assess, develop goals and interventions, therapeutic groups, documentation, and medication management are important
• Shelter and assistance with food should be part of discharge planning

Cultural Implications

• Cultural implications are important components of mental health care
• Minority, race, ethnicity, culture, and cultural norms are considerations
• It is important to consider Western Tradition, Eastern Tradition, and Indigenous culture
• Consider the impact of culture on mental health and cultural barriers to healthcare

Cultural Familiarity

• Cultural awareness, knowledge, encounters, skill, and desire should be present

Ethical and Legal Considerations

• Beneficence (do good), autonomy (right to choices), and justice (fair for all) are components of ethical practice
• Fidelity (truthful, loyal), veracity (tell the truth), and nonmaleficence (do no harm) are components of ethical practice
• Ethical dilemmas exist
• Patients have civil rights

Pharmacogenetic Testing

• DNA profiles are used to determine the most effective medications for a patient
• DNA profiles can predict side effects
• The FDA has not approved pharmacogenetic testing
• Ethical concerns exist regarding pharmacogenetic testing in mental health

Admission

• Informal admission-patient desires admission and is free to leave, with no formal application required
• Voluntary admission-patient or parents of a minor request admission in writing
• Patients can request to leave, but may need permission and be converted to involuntary admission
• Temporary admission occurs when the doctor initiates the process due to danger to self/others or inability to make decisions and lasts 15 days
• During temporary admission the patient will be observed, diagnosed, and treated.
• Involuntary admission happens without patient consent
• Two physicians must sign indicating that the patient's mental health justifies detention and family may be involved
• This is for up to 60 days and reviewed by a panel
• Patients can submit a writ of habeas corpus if they feel they do not need to be there anymore
• A court will then decide if the admission is justified

Discharge

• Conditional Release requires outpatient therapy or some condition to leave
• If the conditions are not me, the patient can be readmitted
• Unconditional Release means the patient can leave and have no obligations.
• Release against medical advice occurs when a physician wants them to stay but poses no immediate danger
• Patients sign a form that it is against medical advice

Patient Rights

• Rights include the right to treatment, refuse treatment and informed consent
• Includes involuntary admission and advance directives
• Includes restraint and seclusion (as a last resort)
• Patients have a right to confidentiality and HIPPA
• Confidentiality after death is maintained
• There is a duty to warn
• There are stipulations for child and elder abuse

Legal Concerns

• Failure to protect patients is a legal concern
• Intentional torts such as threats and abuse are legal concerns
• Unintentional torts include Negligence and Malpractice
• You can be assigned to this person, and you didn't give them their meds, or wrong meds
• Negligence must prove duty, foreseeability, and harm
• Documentation, Violence towards staff and patients should be noted

Nursing Process

• The nursing process is used in mental health as well as for physical care
• Assessment, evaluation, diagnosis, and intervention are components of the nursing process
• Review of body systems, lab data, MSE=Mental status exam, psychosocial assessment, and spiritual/religious assessment are aspects of assessment
• Cultural and social assessment and scales use are appropriate for assessments
• Assessments are concluded only by the verification and validation of information
• Assessment must be geared to the proper age group
• Physical and mental disease can produce symptoms of either state
• Patients being treated for either physical or mental ailments must be asked to rule out other causes or contributing factors
• Nursing diagnoses can be made after validating the patients’ health state
• Goals and plans are patient-centered and culturally appropriate
• Interventions will utilize the team in working toward client goals
• Evaluation of the goal is either met, unmet, or needs changing the plan

Interventions at Basic and Advanced Practice Level

• Included are coordination of care and health teaching/promotion
• Also included is milieu therapy and pharmacological, biological, and integrative treatments
• Therapeutic Relationship and Counseling are components
• Advanced Practice level includes prescriptions, psychotherapy, consultation, documentation, and documentation of nonadherence

Therapeutic Communication and Relationships

• Bases of all psychiatric nursing treatment approaches is establishing an understanding in the client that the nurse-client relationship is safe, confidential, reliable, and has clear boundaries
• Clients with mental health disease may have issues in relationship due to isolation and other factors
• The nurse might be the one person in the life that they can communicate with and establish a relationship
• Therapeutic use of self-using your personality to relate to others and effectively help others

Social vs Therapeutic relationships

• True relationships must involve at least two people
• Relationships are either: Intimate, Social, or Therapeutic

Social Relationships

• Are initiated fir friendship, with an emotional commitment on the part of individuals
• Communication maybe either superficial or further developed

Therapeutic Relationships

• Focused on the client's problems with potential solutions
• Solution of client's choice, encouragement of new skills and behavior change
• Nurses must be accountable and utilize clinical competence
• One must not judge, and supervision by a supervisor or team to establish relationship

Detrimental Nurse-Client Relationship

• Occurs when the nurse tries to meet their own needs or solve the client's problems as a friend/family member would.
• Detrimental relationships often lack boundaries

Personal Characteristics of the Nurse

• Trust, respect, and Rapport
• A bond between the nurse and the client
• Genuineness including self awareness and non-judgemental focus
• Empathy where feelings and are ideas perceived accurately

Boundaries of the Nurse-Client Relationship

• The client's and nurses’ needs are separated

Boundaries Blurred

• Nurses that are overly helpful/controlling
• Those who have narcissistic-selfish image of self

Boundaries Blurred: Transference

• Person unconsciously displaces emotions and behaviors from significant childhood relationships onto persons in current life
• Those in authority in current life are more susceptible to intensified emotions and behaviors
• Negative Transference occurs when it hinders relationship

. Boundaries Blurred: Countertransference

• Nurse displaces feelings related to people in their past onto client
• Client's transference results in countertransference
• One of the common sign is overidentification with clients hindering ability of improvement

Phases of Nurse-Client Relationship

• 1952 Hildegard Peplau established the nurse-patient relationship
• Pre- Orientation allows the nurse to prepare the first contact.
• Orientation phase-goals, limits, etc. are clarified.
• Working phase-maintain, gather more data, facilitate change, evaluate, promote alternative behaviors
• Termination phase-summarize achieved goals, how to continue work that was accomplished
• Also exchange memories, moving towards the end of the relationship as in discharge preparation happens in Termination phase

Beneficial Factors for Relationships

• Consistent, regular, and private interactions
• Being honest and congruent, and allowing it progress at the patients pace

Hampering Factors in Nurse-Cliente Relationships

• Nurse unavailability or lack of contact
• Lack of nurse self-awareness or negativity towards patient

Communication Process

• Stimulus for information, comfort, or advice
• Sender – initiates contact
• Message - sent or expressed
• Variety of media – hearing, visual, touch, smell
• Feedback received

Berol's Model of Communication

• Stimulus reason for communication
• Sender- initiates the interpersonal contact
• Message- information sent
• Media- (auditory- tactile, smell or combination)
• Receiver- response to the message
• Feedback- receiver's response

Communication Types

• all words a person speaks, which Communicates beliefs values perceptions meaning
• Non-verbal : 65%-95% sent message : Body Behavior, Facial expression, Personal appearance

Therapeutic Communication Techniques

• Tools for enhancing communication
• Using silence, Active listening , Listening with empathy
• Clarifying Techniques (Paraphrasing, Restating, Reflecting, Exploring
• Use both open ended and close ended questions to elicit patient response

Communication to avoid

• Excessive questioning,. Giving approval or disapproval
• Giving advice or asking “why” questions questions

Communication Barriers

• Areas problematic for interpreting messages
• Areas such as, Communication styles, Use of eye contact, Perception of touch or cultural bias or prejudices

Preparing for the Interview

• Pace-client should set the pace of the interview. Setting-safe
• Setting-does the client Safe in the chosen environment.
• Introductions or Initiating the interview:
• Where should we start, tell me about Stresses-Difficulties- what brings you here

Attending Behavior

• Culturally appropriate, Maintain Eye contact, Observe Body language.
• Maintain appropiate Distance Intimate( 0-18 inches)- Personal ( 18-40 inches) - Social ( 4-12 feet) Monitor Vocal qualities and Verbal feedback

The Clinical Interview

• Content and direction are decided by client, while the client leads

Guidelines to help

• Speak briefly, or When you do not know what to say, say nothing
• When in doubt focus on feelings or Avoid giving advice or rely on questions
• Pay attention to nonverbal clues by focusing on the client

Common Client Behaviors

• Cries, Asks nurse to keep a secret
• Client asks the the nurse personal question,. Interrupted by another client or communicates thoughts of suicide

Process Recording Written record of a segment of the nurse-patient session that reflects as closely as possible the verbal and nonverbal behaviors of both patient and nurse

• Useful tool for identifying communication patterns

Chapter 10 Responses to Stress

• Severe stress increases risk of mental illness
• Stress can be identified in a variety of settings and each person reacts and copes with stress in different ways
• nursing should promote healing, develop new coping strategies, and help adapt.
• All patients, not just those with mental illnesses

Stress Theory

• Walter Cannon theorized Fight-or-flight response: for situation an individual perceives as threat to survival
• New research indicates that men and women have different neural responses to stress
• Estrogen may reduce stress response in women for blood flow and the release of salivary cortisol

Hans Selye and Lazarus

• Hans Selye: General Adaptation Syndrome (GAS ) has 3 stages: Alarm, Resistance and Exhaustion and Psychological reactions (Lazarus)
• Lazarus identified Types of stress such as Distress-reacts to something and continues to stress or Eustess-reacts to the message

Neurotransmitter Response

• Serotonin synthesis more active during stress response
• May impair serotonin receptor as Corticosteriodes increase risk of depression

Stress Response

• Nervious and immue system interact during alram pahse of GAS
• Can Negativley ability to defend

Mediators

Stressors: Social support: Personality: (How do you perceive it, is it that important

Measurement

• Social Readjustment Rating Scale (Holmes and Rahe; 1967, 1978, 1997 )and positive and or negative
• Tool in book measures stress (pg. 165) , or self-help grps. Spirtuality and culture
• Culture

Assessment

Positive: Solving Using social support, Reframing, Social Supports, Health Sustaining. NEFF (nEGATIVE) : Avoidance and Self Blmae abd effectibe health Copingt

Management Techniques

• Benson's relaxation techniques, meditation, guided imagery, breathing exercises, meditation, exercise

Cognitive Mindfulness, Journaling, Humor

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Explore the nuances of experimental design. Understand control groups, validity, and confounding variables. Learn how to interpret correlations and p-values in research.