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Foundations of Psychiatric Mental Health Nursing

• Mental health is hard to define, lacks a universal definition, and is influenced by various factors
• Mental health is dynamic and always changing
• Personal factors like biology, autonomy, and independence contribute to mental health
• Feelings like self-esteem, growth potential, vitality, and finding meaning are personal factors
• Emotional resilience, a sense of belonging, reality orientation, and coping skills are important personal factors
• Interpersonal factors include effective communication, intimacy, and balanced relationships
• Socio-cultural factors include community, resources, tolerance, diversity, education, employment, and security
• Mental illnesses affect a person's mood, behavior, and thinking processes
• Examples of mental illness include depression, schizophrenia, anxiety, and addiction
• Signs of distress or impaired functioning often indicate mental illness
• General diagnostic criteria include dissatisfaction with abilities, relationships, and life events like personal growth
• The American Psychiatric Association's Diagnostic and Statistical Manual (DSM) is a tool for mental disorders

Diagnostic and Statistical Manual of Mental Disorders (DSM)

• It is a taxonomy of the American Psychiatric Association
• The purposes are to standardize language, define characteristics, and identify disorder causes
• DSM classification helps practitioners consider all factors related to a patient's condition
• The practitioner considers major psychiatric disorders and relevant medical/psychosocial conditions
• Mental disorders are the leading cause of disability in the US and Canada for ages 15-44
• The economic burden of mental illness exceeds all types of cancer
• Deinstitutionalization leads to a "revolving-door" effect, causing rehospitalizations
• People with mental illness face shorter stays, homelessness, comorbidities, and lack resources

Psychiatric Nursing Practice

• Linda Richards was the first American psychiatric nurse
• Hildegard Peplau focused on the therapeutic nurse-client relationship
• J. Mellow focused on the psychosocial needs and strengths of clients
• Basic-Level RN functions include counseling, milieu therapy, self-care activities, and teaching
• Advanced-Level NP functions include psychotherapy, prescriptions, consultation, and evaluation

Therapeutic Relationships

• Trust is built when the client has confidence in the nurse's integrity and reliability
• Behaviors such as caring, listening, and honesty build trust
• Congruence (matching words and actions) is important
• Genuine interest involves the nurse being comfortable, aware, and focused
• Empathy is the ability to perceive and understand the client's feelings
• Acceptance means avoiding judging the person, but setting boundaries
• Positive Regard means having an unconditional, non-judgmental attitude and showing respect

Self-Awareness in Nurse-Client Relationship

• Self-awareness involves understanding one's values, beliefs, and how they affect others
• Therapeutic Use of Self uses personality and experiences to benefit clients
• H. Peplau believed nurses must understand themselves to promote client growth
• The Johari window is a tool to learn about oneself using four quadrants
• Four areas of self include: Open/public, Blind/unaware, Hidden/private, Unknown
• Values provide a sense of right and wrong, and a code of conduct
• Attitudes provides a frame of reference used to organize the world

Relationships

• Self-awareness issues include inappropriate boundaries and sympathy
• Nurses may compensate for feeling sorry for clients by trying to always please them
• Social relationships are for friendship and sharing feelings
• The communication is superficial, advice is given, and outcomes are rarely assessed
• Social interaction should be limited in nurse-client relationships
• Intimate relationships are for emotional commitment with focus on the other persons needs
• Therapeutic relationships focus on the client's needs using communication and understanding

Establishing a Therapeutic Relationship

• Orientation establishes roles and expectations
• The nurse identifies the client's problems
• Nurse-client contracts include confidentiality and duty to warn issues
• Problem identification: issues/concerns identified by client and examination of client's feelings happens in working phase
• Exploitation is examination of feelings and responses, with focus on coping skills/self-image
• Transference: the client unconsciously transfers feelings to the nurse
• Countertransference: the nurse responds based on personal unconscious needs and conflicts
• Termination occurs when the client's issues are resolved, and the relationship ends

Therapeutic Communication

• Therapeutic communication promotes effective information exchange
• The goals are to establish a relationship, identify concerns, facilitate expression, teach skills, and guide solutions
• Therapeutic skills help nurses recognize the issue and respond objectively not jump to conclusions
• Active listening and observation are key
• Nontherapeutic responses cut off communication
• Interpreting signals/cues: verbal/nonverbal messages
• Cues include being clear, direct statements or vague, indirect messages
• Facial expressions connect with words to show speaker's internal dialogue
• Body language can indicate acceptance, defensiveness, or threat
• Vocal cues augment the message through volume, tone, and pauses
• Eye contact assesses others and indicates turns to speak

Aspects of Communication

• Silence can indicate various things
• Messages often contain more meaning than just spoken words
• Validation assesses who, what, when, how, and why
• Proxemics: the study of distance zones like intimate, personal, social, and public
• Therapeutic distance: 3-6 ft. apart

Client's Response to Illness

• Biologic makeup and physical health affect a client's emotional response
• Age, growth, and development affect coping
• Successful psychosocial stages enhance expression of illness
• Heredity and biology are involuntary
• Genetic makeup influences response to illness and treatment
• Healthier people cope better with stress and illness
• People differ in drug metabolism and side effects
• Slower metabolism indicates need for lower doses

Personal Factors

• Self-efficacy is the belief in one's abilities and efforts
• Hardiness is the ability to resist illness, by being committed, in control and having a spirit of challenge
• Resilience involves healthy responses to stress
• Resourcefulness involves problem-solving skills
• Spirituality involves beliefs about the meaning and purpose of life

Interpersonal Factors

• Sense of Belonging is connection with others
• Value: feeling needed and accepted
• Fit: feeling that one meshes or fits in with a system or environment.
• Social Networks are groups of people one knows and feels connected to that help to reduce stress
• Social Support is sustenance that comes from friends, family, and healthcare providers

Cultural Factors

• Cultural Competency emphasizes the need for health care systems and providers to be aware
• Cultural Humility: lifelong process of self reflection
• Beliefs About Causes of Illness:
  • Natural/unnatural
  • Religious/powerful forces
  • Biomedical
• Communication, space, organization, time, environment, and biology all affect the assessment
• The nurse's role is to gather knowledge, and allow the client to be the expert
• An open, objective approach and self-awareness are essential
• The nurse should maintain a genuine attitude
• Recognize own feelings and remember client's responses are unique.