Psychiatric-Mental Health Nursing: Current Theories

• Bulacan State University's vision is to be a progressive university generating institution recognized for excellence, pioneering research, and community engagement.
• This presentation is about Psychiatric-Mental Health Nursing, specifically Unit 1 focusing on Current Theories & Practice
• The presentation is based on the 9th Edition of Sheila L. Videbeck's work, and presented by Mark Jerome M. Delos Santos, an instructor at Bulacan State University - College of Nursing.

Mental Health

• According to the WHO, mental health is a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.
• Mental health is evidenced by satisfying interpersonal relationships, effective behavior and coping, a positive self-concept, and emotional stability.

Factors Influencing Mental Health

• Individual factors include biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, a sense of belonging, reality orientation, and coping or stress management abilities.
• Interpersonal factors involve effective communication, ability to help others, intimacy, and a balance of separateness and connectedness.
• Social/cultural factors encompass a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive and realistic view of one's world.

Mental Illness

• Historically, mental illness was viewed as possession by demons, punishment for religious or social transgressions, weakness of will or spirit, and violation of social norms.
• Mental illness is currently seen as a medical problem.

Mental Disorder

• According to the American Psychological Association (APA), a mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

Diagnostic and Statistical Manual of Mental Disorders (DSM)

• The DSM-IV-TR is a taxonomy published by the APA for use by mental health professionals.
• The DSM-IV-TR describes all mental disorders using specific diagnostic criteria.
• The DSM-IV-TR is based on a multiaxial classification system consisting of five axes:
  • Axis I: Clinical Disorders & other conditions, encompassing all major psychiatric disorders except mental retardation and personality disorders.
  • Axis II: Personality Disorders & Mental Retardation, covering mental retardation, personality disorders, maladaptive personality features, and defense mechanisms.
  • Axis III: General Medical Conditions, which includes current medical conditions.
  • Axis IV: Psychosocial & Environmental Problems, incorporating problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and the legal system.
  • Axis V: Global Assessment of Functioning, where the Global Assessment of Functioning (GAF) score rates the person overall.
• The current edition of the DSM made some major revisions and was released in 2013.
• The current edition describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research.
• The current edition of the DSM classification system includes all major psychiatric disorders.
  • Examples: depression, schizophrenia, anxiety and substance related disorders
• Medical conditions are potentially relevant to understanding or managing the person's mental disorder as well as medical conditions that might contribute to understanding the person.
• Psychosocial and environmental problems that may affect the diagnosis, treatment and prognosis of mental disorders are included.

Historical Perspective

• In ancient times, sickness was seen as displeasure of the gods or punishment for wrongdoing, with treatments including starving, urging, and bloodletting.
• The Period of Enlightenment (1790s) saw the creation of asylums or safe havens to offer protection.
• Sigmund Freud and others studied mental disorders scientifically by the 1900s.
• Psychotropic drugs first became available in 1950.
• Thorazine and Lithium were the first drugs to be developed; MAOI's, TCA, Anxiolytics, and Antipsychotics (Haloperidol) followed 10 years after.
• Deinstitutionalization began with the Community Mental Health Centers Act of 1963.

Mental Illness in the 21st Century

• 56 million Americans have a mental illness (DHHS, 2002).
• Hospital stays are shorter, but there are more numerous admissions, leading to a "revolving door effect".
• There is an increased aggression among mentally ill clients.
• An increased number of people with mental illness are incarcerated.
• There is a growing population of homeless persons with mental illness, including substance abuse.
• The majority of health care dollars are still spent on inpatient psychiatric care, and community services are not adequately funded.
• The "Healthy People 2010" mental health objectives strive to improve care of mentally ill persons.
• Community-based care includes community support services, housing, case management, and residential services outside the hospital.
• Cost containment efforts include utilization review, HMOs, and managed care.
• Cultural considerations: diversity increasing in U.S. in terms of ethnicity and changing family structures.

Psychiatric Nursing Practice

• Linda Richards in 1873, improved nursing care in psychiatric hospitals.
• Linda Richards organized educational programs in a state mental hospitals and was considered the "First American Psychiatric Nurse".
• Linda Richards quoted "the mentally sick should be at least as well cared for as the physically sick".
• McLean Hospital, Belmont MA: site of first training for nurses to work with persons with mental illness.
• The role of nurses expanded with development of somatic therapies requiring nurses to use their medical-surgical skills extensively. This expansion included:
  • Insulin Shock Therapy (1935)
  • Psychosurgery (1936)
  • Electroconvulsive Therapy (1937)
• The first psychiatric nursing textbook (Nursing Mental Diseases) was published in 1920.
• Johns Hopkins was the first school of nursing to include a psychiatric nursing course (1913).
• The National League for Nursing (1950) required schools to include psychiatric nursing experience.
• Hildegard Peplau authored Interpersonal Relations in Nursing (1952).
• Hildegard Peplau authored Interpersonal Technique: The Crux of Psychiatric Nursing
• Hildegard Peplau developed Interpersonal Relations Theory: therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety, forming the foundation for current practice.
• June Mellow developed Nursing Therapy (1986).
• June Mellow focused on client's psychosocial needs and strengths.
• Standards of Psychiatric-Mental Health Clinical Nursing Practice developed in 1973, revised in 1982, 1994, 2000.
• Psychiatric Mental Health Nursing Phenomena of Concern: 12 areas of concern that mental health nurses focus on when caring for clients.

Student Concerns

• Common student concerns include:
  • What if I say the wrong thing?: Listening carefully, showing genuine interest and caring about the client are extremely important.
  • What will I be doing?: Therapeutic nurse-client relations and trust takes time and patience.
  • What if no one will talk to me?: 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 questions?: Remember that questions involving personal matters should not be the first thing a student nursing says to the client. Therapeutic Communication helps.
  • How will I handle bizarre or inappropriate behavior?: Ask your CI and staff nurse for assistance, and clarify the boundaries of the professional relationship.
  • Is my physical safety in jeopardy?: Staff will respond, SN should not become involved.

The Psychiatric Nurse as a Member of the Mental Health Team

• Appreciation of the psychiatric nurses' role is gained through:
  • Recognition of importance of daily interventions with clients
  • Student supervision which helps nursing students realize importance of their specialty
  • Advancement of safe and quality care
• The Mental Health Team comprises:
  • The Psychiatrist makes psychiatric diagnoses and prescribes treatment.
  • The Clinical Psychologist administers and interprets psychological or neuropsychological testing.
  • The Psychiatric Social Worker identifies and deals with social issues that affect clients and their families.
  • The Occupational Therapist provides activities that enable clients to gain skills needed to perform daily activities.
  • The Mental Health Worker or Psychiatric Aide provides direct care to clients, maintaining a therapeutic milieu, under supervision of an RN.
• The Collaborative Process is where the mental health team identifies complex client needs based on input from various team members.

The Role of the Nurse

• Understanding the effects of stress, coping, and adaptation is crucial to health promotion.
• Assessing present and past coping behaviors.
• Assessing developmental and behavioral competencies.
• Generalist Role: Clinically prepared to care for clients with mental illness.
• Advanced-Practice Nurse Role: Prescriptive authority, medication management, consultation.

Essential Qualities of the Psychiatric Nurse

• Therapeutic Use of Self: Forms a trusting relationship that provides comfort, safety, and acceptance.
• Genuineness and Warmth: Implies a sense of openness, realness, and lack of defenses.
• Empathy: Crucial to therapeutic relationship.
• Acceptance: Suggests neither approval nor disapproval but tolerance and appreciation of the client.
• Maturity and Self-Awareness: Major role in nurse's ability to tolerate differences.
• Leadership: Ability to empower, direct, and manage client care.

Self-Awareness Issues

• Everyone has values, beliefs, ideas; nurses need to know what theirs are, not to change them, but to prevent unknown or undue influence on their nursing practice.
• Hints to increase self-awareness: keep a journal, talk to trusted co-workers, examine points of view other than one's own.
• Self awareness is a process by which the nurse gains recognition of their own feelings, beliefs and attitudes.
• The goal of self-awareness is to know oneself so that one's values, attitudes and beliefs are not projected to the client interfering with nursing care.
• Holistic Nursing Model of Self Awareness (Campbell, 1980):
  • Psychological component - knowledge, emotions, motivations, self concept and personality.
  • Physical component - knowledge of personal and general physiology as well as bodily sensation, body image.
  • Environmental component - consists of the socio cultural environment, relationship with others and knowledge of the relationship and others between humans and nature.
  • Philosophical component - sense of life having meaning

Increasing Self Awareness

• Increasing self awareness leads to a goal is to enlarge the area of Quadrant 1 while reducing the size of the other 3 quadrants
• To increase self knowledge, it is necessary to listen to the self.
• Reduce the size of quadrant 2 by listening to and learning from others.
• The final step involves reducing the size of quadrant 3 by self disclosing or revealing to others important aspects of the self.
• Three Principles how the Self functions:
  • A change in any quadrant affects all other quadrants.
  • The smaller quadrant 1, the poorer the communication
  • Interpersonal learning means that a change has taken its place, so quadrant 1 is larger and one or more of the other quadrants is smaller.