Nursing: Mental Health and Community Concepts PDF

NURSING: MENTAL HEALTH AND COMMUNITY CONCEPTS NURSING: MENTAL HEALTH AND COMMUNITY CONCEPTS OPEN RESOURCES FOR NURSING (OPEN RN) Copyright © 2022 by Ernstmeyer, K., and Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. All rights reserved Printed in the United States of America ISBN 13: 978-1-73491-417-7 More information on Creative Commons can be found at https: / /creativecommons.org / licenses/ 4750 Venture Drive, Suite 400 Ann Arbor, MI 48108 800-562-2147 www.xanedu.com CONTENTS Introduction viii Preface ix Standards and Conceptual Approach xv Chapter 1. Foundational Mental Health Chapter 4. Application of the Nursing Concepts 1 Process to Mental Health Care 97 1.1 Introduction 3 4.1 Introduction 99 1.2 Mental Health and Mental Illness 4 4.2 Applying the Nursing Process 100 1.3 Introduction to Trauma-Informed 4.3 Assessment 101 Care 17 4.4 Diagnosis 126 1.4 Stigma 19 4.5 Outcomes Identification 133 1.5 Boundaries 21 4.6 Planning 136 1.6 Establishing Safety 23 4.7 Implementation 142 1.7 Psychiatric-Mental Health Nursing 32 4.8 Evaluation 150 1.8 Learning Activities 35 4.9 NCLEX Next Generation Terminology 152 I Glossary 36 4.10 Spotlight Application 155 Chapter 2. Therapeutic Communication and the Nurse-Client Relationship 39 4.11 Learning Activities 157 IV Glossary 158 2.1 Introduction 41 2.2 Basic Concepts of Communication 42 Chapter 5. Legal and Ethical Considerations in Mental Health Care 163 2.3 Therapeutic Communication 45 5.1 Introduction 165 2.4 Motivational Interviewing 55 5.2 Ethical Principles 166 2.5 Teletherapy and Telehealth 58 5.3 Standards of Care 170 2.6 Learning Activities 60 5.4 Laws, Torts, Malpractice, and II Glossary 61 Disciplinary Actions 173 Chapter 3. Stress, Coping, and Crisis 5.5 Patient Rights 182 Intervention 63 5.6 Learning Activities 190 3.1 Introduction 65 V Glossary 191 3.2 Stress 66 Chapter 6. Psychotropic Medications 193 3.3 Coping 76 6.1 Introduction 195 3.4 Defense Mechanisms 80 6.2 Review of the Central Nervous 3.5 Crisis and Crisis Intervention 83 System 196 3.6 Applying the Nursing Process to 6.3 Antidepressants 201 Stress and Coping 91 6.4 Mood Stabilizers 203 3.7 Learning Activities 94 6.5 Antianxiety Medications 204 III Glossary 95 6.6 Antipsychotics 205 v 6.7 Stimulants 207 Chapter 10. Personality Disorders 327 6.8 Psychoactive Substances and 10.1 Introduction 329 Medications to Treat Substance Use 10.2 Basic Concepts 330 and Withdrawal 208 10.3 Treatment for Personality Disorders 343 6.9 Learning Activities 209 10.4 Applying the Nursing Process to VI Glossary 210 Personality Disorders 346 Chapter 7. Depressive Disorders 213 10.5 Spotlight Application 351 7.1 Introduction 215 10.6 Learning Activities 352 7.2 Causes of Depression 216 X Glossary 354 7.3 Types of Depression 224 Chapter 11. Psychosis and Schizophrenia 355 7.4 Treatments for Depression 231 11.1 Introduction 357 7.5 Applying the Nursing Process to 11.2 Psychosis and Delirium 358 Depressive Disorders 241 11.3 Schizophrenia 362 7.6 Spotlight Application 255 11.4 Applying the Nursing Process to 7.7 Learning Activities 257 Schizophrenia 374 VII Glossary 258 11.5 Spotlight Application 387 Chapter 8. Bipolar Disorders 261 11.6 Learning Activities 388 8.1 Introduction 263 XI Glossary 389 8.2 Basic Concepts of Bipolar Disorders 264 Chapter 12. Childhood and Adolescence 8.3 Treatments for Bipolar Disorders 268 Disorders 391 8.4 Applying the Nursing Process to 12.1 Introduction 393 Bipolar Disorders 275 12.2 Common Disorders and Disabilities 8.5 Spotlight Application 287 in Children and Adolescents 394 8.6 Learning Activities 288 12.3 Psychological Therapies and Behavioral Interventions 418 VIII Glossary 289 12.4 Autism Spectrum Disorder 425 Chapter 9. Anxiety Disorders 291 12.5 Applying the Nursing Process 9.1 Introduction 293 to Mental Health Disorders in 9.2 Basic Concepts 294 Children and Adolescents 430 9.3 Anxiety - Related Disorders 298 12.6 Spotlight Application 442 9.4 Treatments for Anxiety 304 12.7 Learning Activities 443 9.5 Obsessive - Compulsive Disorder 308 XII Glossary 444 9.6 Post-Traumatic Stress Disorder 313 Chapter 13. Eating Disorders 445 9.7 Applying the Nursing Process to 13.1 Introduction 447 Anxiety Disorders 320 13.2 Basic Concepts 448 9.8 Spotlight Application 324 13.3 Treatment for Eating Disorders 459 9.9 Learning Activities 325 13.4 Applying the Nursing Process to IX Glossary 326 Eating Disorders 462 13.5 Spotlight Application 469 vi 13.6 Learning Activities 470 Chapter 17. Vulnerable Populations 629 XIII Glossary 472 17.1 Introduction 631 Chapter 14. Substance Use Disorders 473 17.2 Vulnerable Populations 632 14.1 Introduction 475 17.3 Spotlight Application 652 14.2 Substances: Use, Intoxication, and 17.4 Learning Activities 657 Overdose 477 XVII Glossary 658 14.3 Withdrawal Chapter 18. Environmental Health and Management / Detoxification 498 Emergency Preparedness 659 14.4 Substance-Related and Other 18.1 Introduction 661 Addictive Disorders 505 18.2 Environmental Health 662 14.5 Neurobiology of Substance Use Disorders 510 18.3 Emergency Preparedness, Response, and Recovery 666 14.6 Risk Factors 517 18.4 Nurses’ Roles in Emergency 14.7 Treatment of Substance Use Response 679 Disorders 522 18.5 Spotlight Application 682 14.8 Prevention of Substance Use Disorders 539 18.6 Learning Activities 683 14.9 Applying the Nursing Process to XVIII Glossary 684 Substance Use Disorders 543 Part XIX. Answer Key 685 14.10 Spotlight Application 547 Chapter 1 687 14.11 Learning Activities 548 Chapter 2 688 XIV Glossary 549 Chapter 3 689 Chapter 15. Trauma, Abuse, and Violence 551 Chapter 4 690 15.1 Introduction 553 Chapter 5 691 15.2 Adverse Childhood Experiences 554 Chapter 6 692 15.3 Trauma-Informed Care 559 Chapter 7 693 15.4 Abuse and Neglect 565 Chapter 8 694 15.5 Intimate Partner Violence 573 Chapter 9 695 15.6 Workplace Violence 580 Chapter 10 696 15.7 Spotlight Activity 587 Chapter 11 697 15.8 Learning Activities 589 Chapter 12 698 XV Glossary 590 Chapter 13 699 Chapter 16. Community Assessment 593 Chapter 14 700 16.1 Introduction 595 Chapter 15 701 16.2 Community Health Concepts 597 Chapter 16 702 16.3 Applying the Nursing Process to Chapter 17 703 Community Health 609 Chapter 18 704 16.4 Learning Activities 625 XVI Glossary 626 vii Introduction INTRODUCTION This textbook is an open educational resource with CC-BY licensing developed specifically for prelicensure nursing students. The e-book and downloadable versions are free. Affordable print versions are published in col- laboration with XanEdu and available on Amazon and in college bookstores. Content is based on the Wisconsin Technical College System (WTCS) statewide nursing curriculum for the Nursing Mental Health and Community Concepts course (543-110), the NCLEX-RN Test Plan1, and the American Psychiatric Nurses Association Education Council’s Crosswalk Toolkit: Defining and Using Psychiatric- Mental Health Nursing Skills in Undergraduate Nursing Education.2 Mental health and community health concepts are discussed while emphasizing stress management techniques, healthy coping strategies, referrals to commu- nity resources, and other preventative interventions. Nursing care for individuals with specific mental health and substance use disorders is examined, and the nurse’s role in community health needs assessments and caring for vulnerable populations is introduced. Throughout the print version, URLs and videos are called out within blue boxes with icons. Refer to the online book for the most current URLs to access these supplementary sources. The online book is available at www.cvtc 🎦.edu/‌OpenRN. View a video that provides a quick overview of how to navigate the online version: Nursing: Mental Health and Community Concepts Walkthrough https://wtcs.pressbooks.pub / nursingmhcc/?p=4#oembed-1 1 NCSBN. (n.d.). 2019 NCLEX-RN test plan. https:/‌/www.ncsbn.org/‌2019_RN_TestPlan-English.htm 2 American Psychiatric Nurses Association Education Council, Undergraduate Branch. (2016). Crosswalk toolkit: Defin- ing and using psychiatric-mental health nursing skills in undergraduate nursing education. https:/‌/www.apna.org/‌resources /‌undergraduate-education-toolkit/ viii Preface PREFACE The Open RN project is supported by a $2.5 million grant from the Department of Education to create five free, open-source nursing textbooks. However, this content does not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the federal government. More information about the Open RN grant can be found at cvtc.edu/‌OpenRN. The first three textbooks of the Open RN textbook series, Nursing Pharmacology, Nursing Skills, and Nursing Fundamentals, received a Best OER Award from OE Global in 2020 and 2021. Usage Survey and Feedback We would love to hear if you have integrated some or all of this resource into your course. Please use this short survey to provide constructive feedback or report errors: https://cvtc.az1.qualtrics.com/jfe/form/SV_54PkuNI7Qb0ipJb. Editors Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC Dr. Elizabeth Christman, DNP, RN, CNE Graphics Editor Nic Ashman, MLIS, Librarian, Chippewa Valley Technical College Developing Authors Developing authors remixed existing open educational resources and / or developed content based on evidence- based sources and experience in the mental health field: Dr. Elizabeth Christman, DNP, RN, CNE Dawn Barone, MSN, RN, Chippewa Valley Technical College Sue Dzubay, MSN, RN, CHSE, RN-BC, Chippewa Valley Technical College Kimberly Ernstmeyer, MSN, RN, CNE, CHSE, APNP-BC, Chippewa Valley Technical College Jeanne Green, EdS, MSN, RN, CNE, CHEP, RN-BC, Chippewa Valley Technical College Deb Johnson-Schuh, MSN, RN, Mid-State Technical College Rorey Pritchard, EdS, MEd, MSN, RN-BC, CNOR(E), CNE, Senior RN Clinical Educator, Allevant Solutions, LLC Dr. Miriam Sward, DNP, PMHNP, APNP, Psychiatric Mental Health Nurse Practitioner Alicia Tays, MS, LPC, Counselor Contributors Contributors assisted in creating this textbook: Jane Flesher, MST, Proofreader, Chippewa Valley Technical College Shronda Green, MSN, RN, Gateway Technical College ix Preface Vince Mussehl, MLIS, Open RN Lead Librarian, Chippewa Valley Technical College Joshua Myers, Web Developer, Chippewa Valley Technical College Kelly Nelson, MSN, RN, Mid-State Technical College Amanda Olson-Komisar, CSW, Social Worker; Pupil Services Teacher Assistant, Pepin Area Schools Andrea Olson, MSN, RN, Trempealeau County Healthcare Center Meredith Pomietlo, BA, Retail Design and Marketing, University of Wisconsin – Stout Dominic Slauson, BA, Open RN Instructional Technologist Dr. Jamie Zwicky, EdD, MSN, RN, Moraine Park Technical College Advisory Committee The Open RN Advisory Committee consists of industry members and nursing deans who provide input for the Open RN textbooks and virtual reality scenarios: Jenny Bauer, MSN, RN, NPD-BC, Mayo Clinic Health System Northwest Wisconsin, Eau Claire, WI Lisa Cannestra, Eastern Wisconsin Healthcare Alliance Travis Christman, MSN, RN, Chief Nursing Officer, HSHS Sacred Heart and St. Joseph’s Hospitals Sheri Johnson, UW Population Health Institute Dr. Vicki Hulback, DNP, RN, Dean of Nursing, Gateway Technical College Jenna Julson, MSN, RN, NPD-BC, Nursing Education Specialist, Mayo Clinic Health System Northwest Wisconsin, Eau Claire, WI Brian Krogh, MSN, RN, Associate Dean – Health Sciences, Northeast Wisconsin Technical College Hugh Leasum, MBA, MSN, RN, Nurse Manager Cardiology / ICU, Marshfield Clinic Health System, Eau Claire, WI Pam Maxwell, SSM Health Mari Kay-Nobozny, NW Wisconsin Workforce Development Board Dr. Amy Olson, DNP, RN, Nursing Education Specialist, Mayo Clinic Health System North- west Wisconsin, Eau Claire, WI Gina Petrie, MSN, RN, Dean of Nursing, Chippewa Valley Technical College Rorey Pritchard, EdS, MEd, MSN, RN-BC, CNOR(E), CNE, Senior RN Clinical Educator, Allevant Solutions, LLC Kelly Shafaie, MSN, RN, Associate Dean of Nursing, Moraine Park Technical College Dr. Ernise Watson, PhD, RN, Associate Dean of Nursing, Madison Area Technical College Sherry Willems, HSHS St. Vincent Hospital x Preface Reviewers Dr. Caryn Aleo, PhD, RN, CCRN, CEN, CNE, CNEcl, Pasco-Hernando State College Dawn Barone, MSN, RN, Chippewa Valley Technical College Lisa Bechard, MSN, RN, Mid-State Technical College Shanleigh Bechard, MS, LPC, Beloit Area Community Health Center Ginger Becker, Nursing Student, Portland Community College Nancy Bonard, MSN, RN-BC, St. Joseph’s College of Maine Dr. Joan Buckley, PhD, RN, Nassau Community College Kathleen Capone, MS, RN, CNE, EdD, Utica College Lorraine Chiappetta, MSN, RN, CNE, Emeritus Washtenaw Community College Travis Christman, MSN, RN, Hospital Sister’s Health System Maria Darris, MSN, RN, St. Louis Community College Tamara Davis, MSN, RN, Chippewa Valley Technical College Dr. Andrea Dobogai, DNP, RN, Moraine Park Technical College Dr. Judith Dornbach, DNP, MSN, RN, NEA-BC, Southwestern Oregon Community College Jessica Dwork, MSN-Ed, RN, Maricopa Community Colleges-Phoenix Collège Dr. Terri J. Farmer, PhD, PMHNP-BC, University of Arizona College of Nursing Dr. Rachael Farrell, EdD, MSN, CNE Howard Community College, Columbia, MD Dr. Vivienne Friday, EdD, MSN, RN, CNE, MSOL, Goodwin University Jocelyn E. Goodwin, MSN, RN, Paradise Valley Community College Kerry L. Hamm, MSN, RN, Lakeland University Julia Harelstad, MSN, RN, Mayo Clinic Health System, Eau Claire WI Deborah Harmon, BSN, RN, AdventHealth Zephyrhills / Dade City Melissa Hauge, MSN, RN, Madison College Camille Hernandez, MSN, APRN-Rx, ACNP / FNP, Hawaii Community College – Palamanui Katherine Howard, MS, RN-BC, CNE, Middlesex College New Jersey Susan Jepsen, MSN, RN, CNE, Lansing Community College Eric Johnson, MSN, RN, Chippewa Valley Technical College Dr. Kathi L. Johnson, DNP, MS, RN-BC, CNE, Howard Community College Jenna Julson, MSN, RN, NPD-RN, Mayo Clinic Health System Dr. Andrew D. Kehl, DNP, MSN, MPH, APRN, RN, Vermont Technical College Kathryn Kieran, MSN, PMHNP-BC, MGH Institute of Health Professions Lindsay Kuhlman, BSN, RN, HSHS Sacred Heart Kathy L. Loppnow, MSN, RN, WTCS Health Science Education Director (retired) Dawn M. Lyon, MSN, RN, Saint Clair County Community College xi Preface Dr. Erin Micale-Sexton, DNP, MSN-RN, CNL, Lansing Community College, Madonna Uni- versity, Arizona College Sara K. Mitchell, MSN, RN, Fox Valley Technical College Dr. Jamie Murphy, PhD, RN, SUNY Delhi Kelly Nelson, MSN, RN, Mid-State Technical College Tram Nguyen, Nursing Student, Portland Community College Dr. Tennille O’Connor, DNP, RN, CNE, College of Central Florida Andrea Olson, MSN, RN, Trempealeau County Health Care Center Amanda Olson-Komisar, CSW, Social Worker; Pupil Services Teacher Assistant, Pepin Area Schools Dr. Grace Paul, DNP, MPhil, RN, CNE, Glendale Community College Krista Polomis, MSN, RN, CNE, Nicolet College Mary A. Pomietlo, MSN, RN, CNE, University of Wisconsin – Eau Claire Cassandra Porter, MSN, RN, Lake Land College Rachel Potaczek, BSN, RN, Chippewa County Department of Public Health Rorey Pritchard, EdS, MSN, RN-BC, NPD, CNOR(E), CNE, Allevant Solutions, LLC Dr. Debbie Rickeard, DNP, MSN, BScN, BA, RN, CNE, CCRN, University of Windsor Dr. Argie Rivera, DNP, MAN, PMHNP-BC, Polara Health, Grand Canyon University, Cara Behavioral Health Kathleen S. Rizzo, MSN, RN, St. Louis Community College at Forest Park Ann K. Rosemeyer, MSN, RN, Chippewa Valley Technical College Brenda Scheurer, MS, PMP, Eau Claire City-County Health Department Cynthia Schroder, MSN, RN, FNP, Yavapai College Katherine A. Sell, MSN, RN, IBCLC, CNE, University of Wisconsin – Eau Claire Alexis Smith, MScN, RN, Western University Justin Spargrove, MSN, RN, Southwest Wisconsin Technical College Morgan Stock, MSN-Ed, RN, CNE, University of Arizona Dr. Miriam A. Sward, DNP, PMHNP, APNP, Northlakes Community Clinic Maria E. Thomas, MSN, MS, RN, CNE, Yavapai College Jane Trainis, MS, PMHCNS-BC, CNE, Community College of Baltimore County Jennie E. Ver Steeg, MLIS, AHIP, Mercy College of Health Sciences Emily Vergenz, MSN, RN, Lakeshore Technical College Devon Rice Weaver, MSN, RN, Clatsop Community College Dr. Nancy Whitehead, PhD, APNP, RN, Milwaukee Area Technical College xii Preface Licensing / Terms of Use This textbook is licensed under a Creative Commons Attribution 4.0 International (CC-BY) license unless oth- erwise indicated, which means that you are free to: SHARE – copy and redistribute the material in any medium or format ADAPT – remix, transform, and build upon the material for any purpose, even commercially The licensor cannot revoke these freedoms as long as you follow the license terms. Attribution: You must give appropriate credit, provide a link to the license, and indicate if any changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use. No Additional Restrictions: You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. Notice: You do not have to comply with the license for elements of the material in the public domain or where your use is permitted by an applicable exception or limitation. No Warranties Are Given: The license may not give you all of the permissions necessary for your intended use. For example, other rights such as publicity, privacy, or moral rights may limit how you use the material. Attribution Some of the content for this textbook was adapted from the following open educational resources. For specific reference information about what was used and / or changed in this adaptation, please refer to the footnotes at the bottom of each page of the book. Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0 Nursing Management and Professional Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0 Nursing Pharmacology by Chippewa Valley Technical College is licensed under CC BY 4.0 mhGAP Intervention Guide – Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 Human Relations by LibreTexts is licensed under CC BY-NC-SA 4.0 Anatomy and Physiology by OpenStax is licensed under CC BY 4.0. Access for free at https:/‌/ openstax.org/‌books/‌anatomy-and-physiology/‌pages/‌1-introduction Nursing Care at the End of Life by Lowey is licensed under CC BY-NC-SA 4.0 Doing What Matters in Times of Stress: An Illustrated Guide by World Health Organization is licensed under CC BY-NC-SA 3.0 IGO StatPearls by Orenstein & Lewis is licensed under CC BY 4.0 Psychology 2e by OpenStax is licensed under CC BY 4.0. Access for free at https:/‌/openstax.org /‌books/‌psychology-2e/‌pages/‌1-introduction StatPearls by Jabbari & Rouster is licensed under CC BY 4.0 xiii Preface StatPearls by Sheffler, Reddy, and Pillarisetty is licensed under CC BY 4.0 StatPearls by Dhaliwal and Gupta is licensed under CC BY 4.0 StatPearls by Shin and Saadabadi is licensed under CC BY 4.0 StatPearls by Wilson and Tripp is licensed under CC BY 4.0 StatPearls by Chokhawala and Stevens is licensed under CC BY 4.0 StatPearls by Ahuja and Abdijadid is licensed under CC BY 4.0 StatPearls by Padda and Derian is licensed under CC BY 4.0 Foundations of Addiction Studies by Flori and Trytek is licensed under CC BY-NC-SA 4.0 StatPearls by Vasan and Kumar is licensed under CC BY 4.0 StatPearls by Kang, Galuska, & Ghassemzadeh is licensed under CC BY 4.0 Action Steps Using ACEs and Trauma-Informed Care: A Resilience Model by Laurie Leitch is li- censed under CC BY 4.0 StatPearls by Kisling and Das is licensed under CC BY 4.0 Community Tool Box by Center for Community Health and Development at the University of Kansas is licensed under CC BY NC SA 3.0 Daily New Confirmed COVID-19 Deaths Per Million People by Our World in Data is licensed under CC BY 4.0 The Emerging Neurobiology of Bipolar Disorder by Harrison, Geddes, & Tunbridge is licensed under CC BY 4.0 StatPearls by Fisher, Hany, and Doerr is licensed under CC BY 4.0 StatPearls by Lewis and O’Day is licensed under CC BY 4.0 StatPearls by Vasan and Padhy is licensed under CC BY 4.0 The Scholarship of Writing in Nursing Education: 1st Canadian Edition by Lapum, St-Amant, Hughes, Tan, Bogdan, Dimaranan, Frantzke, and Savicevic is licensed under CC BY-SA 4.0 Suggested attribution statement: Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing Mental Health and Community Concepts by Chippewa Valley Technical College is licensed under CC BY 4.0 xiv Standards and Conceptual Approach STANDARDS AND CONCEPTUAL APPROACH The Open RN Nursing Mental Health and Community Concepts textbook is based on several external standards and uses a conceptual approach. External Standards American Nurses Association (ANA) The ANA establishes Standards for Professional Nursing Practice and the Nursing Code of Ethics.3,4,5 https:/‌/www.nursingworld.org/‌ana/‌about-ana/‌standards/ American Psychiatric Nurses Association (APNA) The APNA advances the science and education of psychiatric-mental health nursing. The APNA is committed to the practice of psychiatric-mental health nursing, health and wellness promotion through identification of mental health issues, prevention of mental health problems, and the care and treatment of persons with mental health disorders.6 https:/‌/www.apna.org/ American Psychiatric Nurses Association Education Council, Undergraduate Branch The APNA created a toolkit to help define and integrate psychiatric-mental health nursing content into under- graduate nursing curricula.7 https:/‌/www.apna.org/‌resources/‌undergraduate-education-toolkit/ Substance Abuse and Mental Health Services Administration (SAMHSA) The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation and to improve the lives of individuals living with mental health and substance use disorders and their 3 American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. 4 American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https:/‌/www.nursingworld.org/‌practice-policy/‌nursing-excellence/‌ethics/‌code-of-ethics-for-nurses/ 5 American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Nursesbooks.org. 6 American Psychiatric Nurses Association. https:/‌/www.apna.org/ 7 American Psychiatric Nurses Association Education Council, Undergraduate Branch. (2016). Crosswalk toolkit: Defin- ing and using psychiatric-mental health nursing skills in undergraduate nursing education. https:/‌/www.apna.org/‌resources /‌undergraduate-education-toolkit/ xv Standards and Conceptual Approach families. SAMHSA’s mission is to reduce the impact of substance abuse and mental illness on America’s commu- nities and draws advice from public members and professionals in the field of substance abuse and mental health.8 https:/‌/www.samhsa.gov/ The National Council Licensure Examination for Registered Nurses: NCLEX-RN Test Plans The NCLEX-RN test plans are updated every three years to reflect fair, comprehensive, current, and entry-level nursing competency.9 https:/‌/www.ncsbn.org/‌nclex.htm The National League of Nursing (NLN): Competencies for Graduates of Nursing Programs NLN competencies guide nursing curricula to position graduates in a dynamic health care arena with practice that is informed by a body of knowledge to help ensure the public receives safe, quality care.10 https:/‌/www.nln.org/e‌ ducation/n ‌ ursing-education-competencies/competencies-for-graduates -of-nursing-programs American Association of Colleges of Nursing (AACN): The Essentials: Competencies for Professional Nursing Education The AACN provides a framework for preparing individuals as members of the discipline of nursing, reflecting expectations across the trajectory of nursing education and applied experience. https:/‌/www.aacnnursing.org/‌Portals/‌42/‌AcademicNursing/‌pdf/Essentials-2021.pdf Quality and Safety Education for Nurses (QSEN) Institute: Prelicensure Competencies Quality and safety competencies include knowledge, skills, and attitudes to be developed in nursing prelicensure programs. QSEN competencies include patient-centered care, teamwork and collaboration, evidence-based prac- tice, quality improvement, safety, and informatics.11 https:/‌/qsen.org/‌competencies/ 8 Substance Abuse and Mental Health Services Administration. (n.d.). Strategic plan FY2019-FY2023. https:/‌/www.samhsa.gov/‌sites/‌default/‌files/‌samhsa_strategic_plan_fy19-fy23_final-508.pdf 9 NCSBN. (n.d.). 2019 NCLEX-RN test plan. https:/‌/www.ncsbn.org/‌2019_RN_TestPlan-English.htm 10 National League of Nursing. Competencies for graduates of nursing programs. https:/‌/www.nln.org/ education / nursing-education-competencies / competencies-for-graduates-of-nursing-programs 11 QSEN. (n.d.). About. https:/‌/qsen.org/‌about-qsen/ xvi Standards and Conceptual Approach Wisconsin State Legislature, Administrative Code Chapter N6 The Wisconsin Administrative Code governs the Registered Nursing and Practical Nursing professions in Wisconsin.12 https:/‌/docs.legis.wisconsin.gov/‌code/‌admin_code/‌n / 6 Healthy People 2030 Healthy People 2030 envisions a society in which all people can achieve their full potential for health and well-being across the life span. Healthy People provides objectives based on national data and includes social determinants of health.13 https:/‌/health.gov/‌healthypeople Conceptual Approach The Open RN Nursing Mental Health and Community Concepts textbook incorporates the following concepts: Holism. Florence Nightingale taught nurses to focus on the principles of holism, including wellness and the inter- relationship of human beings and their environment. This textbook encourages holistic nursing care by addressing the impact of social determinants of health (SDOH) on mental health. Evidence-Based Practice (EBP). Evidence-based practices are referenced by footnotes throughout the textbook. To promote the development of digital literacy, URLs are provided to credible, free online resources that supple- ment content. The Open RN textbooks will be updated as new EBP is established and after the release of updated NCLEX Test Plans every three years. Clinical Judgment. Associated unfolding case studies are written to reflect the NCSBN Clinical Judgment Mea- surement Model used on the NCLEX-RN. Formative assessments encourage students to recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.14 Cultural Competency. Nurses have an ethical obligation to practice with cultural humility and provide cultur- ally responsive care to the clients and communities they serve based on the ANA Code of Ethics15 and the ANA Scope and Standards of Practice.16 12 Wisconsin State Legislature. (2018). Chapter 6: Standards of practice for registered nurses and licensed practical nurses. Board of Nursing. https:/‌/docs.legis.wisconsin.gov/‌statutes/‌statutes/‌441 13 Healthy People 2030. (n.d.). Social determinants of health. U.S. Department of Health and Human Services. https:/‌/ health.gov/‌healthypeople/‌objectives-and-data/‌social-determinants-health 14 Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the national council of state boards of nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education. 58(2), 72-78. https:/‌/doi.org/‌10.3928 /‌01484834-20190122-03 15 American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https:/‌/www.nursingworld.org/‌practice-policy/‌nursing-excellence/‌ethics/‌code-of-ethics-for-nurses/ 16 American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. xvii Standards and Conceptual Approach Safe, Quality, Patient-Centered Care. Content reflects the priorities of safe, quality, patient-centered care. Clear and Inclusive Language. Clear language is used based on preferences expressed by prelicensure nursing students to enhance understanding of complex concepts.17 “They” is used as a singular pronoun to refer to a person whose gender is unknown or irrelevant to the context of the usage, as endorsed by APA style. It is inclusive of all people and helps writers avoid making assumptions about gender.18 Open-Source Images and Fair Use. Images are included to promote visual learning. Students and faculty can reuse open-source images by following the terms of their associated Creative Commons licensing. Some images are included based on Fair Use as described in the “Code of Best Practices for Fair Use and Fair Dealing in Open Education” presented at the OpenEd 2020 conference. Refer to the footnotes of images for source and licensing information throughout the text. Open Pedagogy. Students are encouraged to contribute to the Open RN project in meaningful ways by reviewing content for clarity and assisting in the creation of open-source images.19 Supplementary Material Provided Several supplementary resources are provided with this textbook. Supplementary, free videos promote student understanding of concepts and procedures. Online, interactive, and written learning activities provide formative feedback. Critical thinking questions encourage the development of clinical judgment as students apply content to realistic patient scenarios. Free downloadable textbook versions are available for offline use. Affordable soft cover print versions are published by XanEdu and available on Amazon and in college bookstores based on the finding that over 65% of students prefer a print version of their textbooks.20 17 Verkuyl, M., Lapum, J., St-Amant, O., Bregstein, J., & Hughes, M. (2020). Healthcare students’ use of an e-textbook open educational resource on vital sign measurement: A qualitative study. Open Learning: The Journal of Open, Distance and e-Learning. https:/‌/doi.org/‌10.1080/‌02680513.2020.1835623 18 American Psychological Association. (2021). Singular “They.” https:/‌/apastyle.apa.org/‌style -grammar-guidelines / grammar / singular-they 19 The Open Pedagogy Notebook by Steel Wagstaff is licensed under CC BY 4.0 20 Verkuyl, M., Lapum, J., St-Amant, O., Bregstein, J., & Hughes, M. (2020). Healthcare students’ use of an e-textbook open educational resource on vital sign measurement: A qualitative study. Open Learning: The Journal of Open, Distance and e-Learning. https:/‌/doi.org/‌10.1080/‌02680513.2020.1835623 xviii Chapter 1 Foundational Mental Health Concepts Foundational Mental Health Concepts Chapter 1 1.1 INTRODUCTION My Notes Learning Objectives Describe basic concepts related to mental health care Establish a safe environment for clients, nurses, and other staff Discuss psychiatric-mental health nursing and associated standards of care Apply principles of patient-centered care while considering client diversity across the life span Mental health is an important part of everyone’s overall health and well-being. Mental health includes our emo- tional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices. Mental health is important at every stage of life, from childhood to adolescence and through adulthood.1 This chapter will provide an overview of mental health, mental illness, and mental health nursing. As with all areas of nursing, when caring for a person with a mental health diagnosis, it is important to focus on patient-centered care and evaluate the effectiveness of care in terms of the highest level of functioning that person is able to achieve. Reflective Questions ‌As we begin this chapter, reflect on the following questions: 1. How do you define mental health? 2. How do you define mental illness? 3. How do you differentiate between the two with everyday functioning? 4. Consider how you communicate with clients. Which therapeutic techniques have you found work best? What interferes with effective communication? 5. How does ineffective communication impact client care? How can it affect your nursing license or create legal implications? 1 Centers for Disease Control and Prevention. (2021, July 20). Mental health. https:/‌/www.cdc.gov/‌mentalhealth/‌index.htm 3 Nursing Mental Health and Community Concepts My Notes 1.2 MENTAL HEALTH AND MENTAL ILLNESS Mental health is an essential component of health. The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Mental health is a state of well-being in which an individual realizes their own abilities, copes with the normal stresses of life, works productively, and contributes to their community. The promotion, protection, and restoration of mental health is a vital concern of individuals, nurses, communities, and societies throughout the world.1 According to the American Psychiatric Association, mental illness is a health condition involving changes in emotion, thinking, or behavior (or a combination of these) associated with emotional distress and problems func- tioning in social, work, or family activities.2 Mental illness is common in the United States. Nearly one in five (19 percent) of adults experience some form of mental illness, one in twelve (8.5 percent) have a substance use disorder, and one in 24 (4 percent) have a serious mental illness.3 Poor mental health increases the risk of chronic physical illnesses, such as heart disease, cancer, and strokes, and can lead to thoughts and intentions of suicide. Suicide is a common symptom associated with mental illness and is the second leading cause of death in Americans aged 15-34.4 🎦 View a video: The WHO Special Initiative on Mental Health (2019-2023).5 1 World Health Organization. (2018, March 30). Mental health: Strengthening our response. https:/‌/www.who.int/‌news -room/‌fact-sheets/‌detail/‌mental-health-strengthening-our-response 2 American Psychiatric Association. (n.d.). What is mental illness? https:/‌/www.psychiatry.org/‌patients-families/‌what-is -mental-illness 3 American Psychiatric Association. (n.d.). What is mental illness? https:/‌/www.psychiatry.org/‌patients-families/‌what-is -mental-illness 4 Centers for Disease Control and Prevention. (2021, July 20). Mental health. https:/‌/www.cdc.gov/‌mentalhealth/‌index.htm 5 World Health Organization (WHO). (2020, July 20). WHO special initiative on mental health (2019-2023) [Video]‌. YouTube. All rights reserved. https://youtu.be / ti7OIMq7V9I 4 Foundational Mental Health Concepts Chapter 1 Mental Health Continuum My Notes Mental health fluctuates over the course of an individual’s life span and can range from well-being to emotional problems and / or mental illness as indicated on the mental health continuum illustrated in Figure 1.1.6,7,8 Figure 1.1 Mental Health Continuum (Used with permission.) Well-being is on the “healthy” range of the mental health continuum in which individuals are experiencing a state of good mental and emotional health. They may experience stress and discomfort resulting from occasional problems of everyday life, but they are able to cope effectively with these stressors and experience no impairments to daily functioning. On the other end of the mental health continuum are mental health problems where individuals have progres- sively more difficulty coping with serious problems and stressors. Within this range are two categories: emotional problems / concerns and mental illness. For individuals experiencing emotional problems, discomfort has risen to a level of mild to moderate distress, and they are experiencing mild or temporary impairments in functioning, such as insomnia, lack of concentration, or loss of appetite. As their level of distress increases, they may seek treatment and often start with visiting their primary health care provider. Emotional problems become classified as “mental illness” when an individual’s level of distress becomes signifi- cant, and they have moderate to severe impairment in daily functioning at work, school, or home. Mental illness includes relatively common disorders, such as depression and anxiety, as well as less common disorders such as schizophrenia. Mental illness is characterized by alterations in thinking, mood, or behavior. The term serious 6 “continuum.jpg” by University of Michigan is used with permission. Access the original at https:/‌/hr.umich.edu/‌benefits -wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well-being/‌mental-emotional-health/‌mental-emotional-health-classes -training-events/‌online-tutorial-supervisors/‌section-1-what-you-need-know-about-mental-health-problems-substance -misuse 7 William, S. (2021, January 18). The continuum between temperament and mental illness as dynamical phases and transi- tions. Frontiers in Psychiatry, 11, 1617. https:/‌/doi.org/‌10.3389/‌fpsyt.2020.614982 8 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health problems and sub- stance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well-being/‌mental-emotional -health/‌mental-emotional-health-classes-training-events/‌online-tutorial-supervisors/‌section-1-what-you-need-know-about -mental-health-problems-substance-misuse 5 Nursing Mental Health and Community Concepts My Notes mental illness refers to mental illness that causes disabling functional impairment that substantially interferes with one or more major life activities. The Americans With Disabilities Act defines major life activities as, “caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.”9 Examples of serious mental illnesses that commonly interfere with major life activities include major depressive disorder, schizophrenia, and bipolar disorder.10 Individuals with serious mental illnesses may experience long-term impairments ranging from moderate to disabling in nature, but many can lead productive lives with effective treatment. Roughly half of schizophrenia patients recovered or significantly improved over the long-term, suggesting that functional remis- sion is possible.11,12 Mental health providers, such as psychiatrists, psychologists, therapists, social workers, or advanced practice men- tal health nurses, use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association to assess a client’s signs and symptoms and determine a mental health diagnosis. The manual lists diagnostic criteria including feelings, behaviors, and time frames to be officially classi- fied as a mental health disorder.13 There are more than 200 types of mental illness. People can experience different types of mental health disorders, and different disorders can occur at the same time or vary in intensity over time. Mental illness can be ongoing, occur over a short period of time, or be episodic (i.e., it comes and goes with discrete beginnings and ends).14 🔗 Read more information about specific mental health disorders at the Medline Plus Mental Health and Behavior web page. Assessing Dysfunction and Impairment Mental health disorders have been defined as a type of dysfunction that causes distress or impaired functioning and deviates from typical or expected behavior according to societal or cultural standards. This definition includes three components referred to as dysfunction, distress, and deviance.15 Dysfunction includes disturbances in a person’s thinking, emotional regulation, or behavior that reflects signifi- cant dysfunction in psychological, biological, or developmental processes underlying mental functioning. In other words, dysfunction refers to a breakdown in cognition, emotion, and / or behavior. For instance, an individual 9 Office of Federal Contract Compliance Programs. (2009, January 1). ADA Amendments Act of 2008 frequently asked ques- tions. U.S. Department of Labor. https:/‌/www.dol.gov/‌agencies/‌ofccp/‌faqs/‌americans-with-disabilities-act-amendments 10 American Psychiatric Association. (n.d.). What is mental illness? https:/‌/www.psychiatry.org/‌patients-families/ what-is-mental-illness 11 Vita, A., & Barlati, S. (2018). Recovery from schizophrenia: Is it possible? Current Opinion in Psychiatry, 31(3), 246–255. https:/‌/doi.org/‌10.1097/‌YCO.0000000000000407 12 Rakitzi, S., Georgila, P., & Becker-Woitag, A. P. (2021). The recovery process for individuals with schizophrenia in the context of evidence-based psychotherapy and rehabilitation: A systematic review. European Psychologist, 26(2), 96–111. https: /‌/doi.org/‌10.1027/‌1016-9040/‌a000400 13 American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5. 14 Centers for Disease Control and Prevention. (2021, July 20). Mental health. https:/‌/www.cdc.gov/‌mentalhealth/index. htm 15 Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 6 Foundational Mental Health Concepts Chapter 1 experiencing a delusion that they are an omnipotent deity has a breakdown in cognition because their thought My Notes processes are not consistent with reality. An individual who is unable to experience pleasure has a breakdown in emotion, and an individual who is unable to leave home and attend work due to fear of having a panic attack is exhibiting a breakdown in behavior.16 Distress refers to psychological and / or physical pain. Simply put, distress refers to suffering. For example, the loss of a loved one causes anyone to experience emotional pain, distress, and a temporary impairment in functioning. Impairment refers to a limited ability to engage in activities of daily living (i.e., they cannot maintain personal hygiene, prepare meals, or pay bills) or participate in social events, work, or school. Impairment can also interfere with the ability to perform important life roles such as a caregiver, parent, or student.17 Deviance refers to behavior that violates social norms or cultural expectations because one’s culture determines what is “normal.” When a person is described as “deviant,” it means they are not following the stated and unstated rules of their society (referred to as social norms).18 Nurses complete and document initial and ongoing assessments of dysfunction, distress, and behavior associated with an individual’s diagnosed mental health disorder. The World Health Organization Disability Assessment Scale (WHODAS) is a tool recommended in the DSM-5 to assess impairments resulting from mental illness.19 The WHODAS is a generic assessment instrument that provides a standardized method for measuring health and disability across cultures.20 The WHODAS assesses functioning in six domains: cognition, mobility, self-care, getting along, life activities, and participation.21 🔗 View the WHODAS 2.0 web page. The Global Assessment of Functioning (GAF) was historically used to rate the seriousness of a mental illness and measure how symptoms affect an individual’s day-to-day life on a scale of 0 to 100. It is an overall (global) measure of how clients are doing and rates psychological, social, and occupational functioning on the continuum from mental well-being to serious mental illness. The higher the score, the better the daily functioning. The GAF was omitted from the DSM-5 because it had questionable validity and reliability, but some government agencies and insurance companies continue to include it in paperwork to assess client functioning.22 16 Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 17 Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 18 Culture and Psychology by Worthy, Lavigne, and Romero is licensed under CC BY-NC-SA 4.0 19 Office of Federal Contract Compliance Programs. (2009, January 1). ADA Amendments Act of 2008 frequently asked ques- tions. U.S. Department of Labor. https:/‌/www.dol.gov/‌agencies/‌ofccp/‌faqs/‌americans-with-disabilities-act-amendments 20 World Health Organization. (2012). Measuring health and disability: Manual for WHO disability assessment schedule (WHODAS 2.0). [Manual]‌. https:/‌/www.who.int/‌publications/‌i / item/‌measuring-health-and-disability-manual-for-who -disability-assessment-schedule-(-whodas-2.0) 21 National Academies of Sciences, Engineering, and Medicine. (2016). Measuring specific mental illness diagnoses with functional impairment: Work-shop summary. J. C. Rivard and K. Marton, Rapporteurs. Committee on National Statistics and Board on Behavioral, Cognitive, and Sensory Sciences, Division of Behavioral and Social Sciences and Education. Board on Health Sciences Policy, Institute of Medicine. The National Academies Press. http:/‌/elibrary.pcu.edu.ph:9000/‌digi/‌NA02 /‌2016/‌21920.pdf 22 Smith, M. (2021, February 6). What is the global assessment of functioning (GAF) scale? WebMD. https:/‌/www.webmd.com/‌mental-health/‌gaf-scale-facts 7 Nursing Mental Health and Community Concepts My Notes Recovery Mental illness is treatable. Research shows that people with mental illness can get better, and many recover com- pletely.23 The majority of individuals with mental illness continue to function in their daily lives. Recovery refers to a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.24 Dimensions that support a life in recovery include the following: Health: Overcoming or managing one’s disease(s), as well as living in a physically and emotion- ally healthy way Home: Having a stable and safe place to live Purpose: Participating in meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society Community: Enjoying relationships and social networks that provide support, friendship, love, and hope Early Signs of Mental Health Problems Mental health problems are common. We all experience problems and stressors from daily living at the milder end of the mental health continuum, and at some point in our lives, we are likely to experience emotional problems or concerns. Mental illness, though less common, is nevertheless a frequent occurrence, and it is estimated that approximately one in five Americans will personally experience a mental illness in their lifetime.25,26 Nurses in all care settings must recognize signs and symptoms of diagnosed and undiagnosed emotional and men- tal health problems in clients. Each mental health disorder has specific signs and symptoms, but common signs of mental health problems in adults and adolescents are as follows27: Excessive worrying or fear Excessive sad or low feelings Confused thinking or problems concentrating and learning Extreme mood changes, including uncontrollable “highs” or feelings of euphoria Prolonged or strong feelings of irritability or anger Avoidance of friends and social activities 23 Centers for Disease Control and Prevention. (2021, July 20). Mental health. https:/‌/www.cdc.gov/‌mentalhealth/ index.‌htm 24 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 25 William, S. (2021, January 18). The continuum between temperament and mental illness as dynamical phases and tran- sitions. Frontiers in Psychiatry, 11, 1617. https:/‌/doi.org/‌10.3389/‌fpsyt.2020.614982 26 National Alliance on Mental Illness (NAMI). (2022, June). Mental health by the numbers. https:/‌/www.nami.org /‌mhstats#:~:text=21%25%20of%20U.S.%20adults%20experienced,represents%201%20in%2020%20adults 27 National Alliance on Mental Illness. (n.d.). Warning signs and symptoms. https:/‌/nami.org/‌About-Mental-Illness /‌Warning-Signs-and-Symptoms 8 Foundational Mental Health Concepts Chapter 1 Difficulty understanding or relating to other people My Notes Changes in sleeping habits or feeling tired and low energy Changes in eating habits, such as increased hunger or lack of appetite Changes in sex drive Disturbances in perceiving reality referred to as hallucinations (i.e., when a person senses things that don’t exist in reality) Inability to perceive changes in one’s own feelings, behavior, or personality (i.e., lack of insight) Misuse of substances like alcohol, drugs, or prescription medications Multiple physical ailments without obvious causes (such as headaches, stomachaches, or vague and ongoing “aches and pains”) Thoughts of suicide Inability to carry out daily activities or handle daily problems and stress Intense fear of weight gain or being overly concerned with appearance Mental health disorders can also be present in young children. Because children are still learning how to identify and talk about thoughts and emotions, their most obvious symptoms are behavioral or complaints of physical symptoms. Behavioral symptoms in children can include the following28: Changes in school performance Excessive worry or anxiety, for example fighting to avoid going to bed or school Hyperactive behavior Frequent nightmares Frequent disobedience or aggression Frequent temper tantrums 🎦 View the following YouTube video about warning signs of mental health problems29: 10 Com- mon Warning Signs of a Mental Health Condition. Cultural Impact Cultural values and beliefs impact how a person views certain ideas or behaviors. In the case of mental health, it can impact whether or not the individual seeks help, the type of help sought, and the support available. Every individual has different cultural beliefs and faces a unique journey to recovery. In general, historically marginalized 28 National Alliance on Mental Illness. (n.d.). Warning signs and symptoms. https:/‌/nami.org/‌About-Mental-Illness /‌Warning-Signs-and-Symptoms 29 NAMI. (2015, February 2). 10 common warning signs of a mental health condition [Video]‌. YouTube. All rights reserved. https://youtu.be / zt4sOjWwV3M 9 Nursing Mental Health and Community Concepts My Notes communities in the United States are less likely to access mental health treatment, or they wait until symptoms are severe before seeking assistance.30 Four ways that culture can impact mental well-being are the following31: Cultural stigma. Every culture has a different perspective on mental health, and most cultures have a stigma surrounding mental health. Mental health challenges may be considered a weak- ness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Describing symptoms. Culture can influence how people describe or feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. For example, members of the Amish community are typically stoic and endure physical and emotional pain without complaining. Community support. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Because of existing stigma, it can be challenging for individuals to find mental health treatment and support. Resources. When looking for mental health treatment, it can be difficult to find resources and treatment options that take into account a specific culture’s concerns and needs. Nurses can help clients by understanding the role culture plays in their mental health. If potential signs of undiag- nosed or poorly managed mental health disorders are present, nurses should make appropriate referrals for further assessment and follow-up. 🔗 Read more about cultural diversity and providing culturally responsive care in the “Diverse Patients” chapter of Open RN Nursing Fundamentals. Causes of Mental Illness Mental health researchers have developed several theories to explain the causes of mental health disorders, but they have not reached consensus. One factor in which they all agree is that an individual is not at fault for the condition, and they cannot simply turn symptoms on or off at will. There are likely several factors that combine to trigger a mental health disorder, including environmental, biological, and genetic factors.32 30 Mental Health First Aid USA. (2019, July 11). Four ways culture impacts mental health. National Council for Mental Wellbeing. https:/‌/www.mentalhealthfirstaid.org/‌2019/‌07/‌four-ways-culture-impacts-mental-health/ 31 Mental Health First Aid USA. (2019, July 11). Four ways culture impacts mental health. National Council for Mental Wellbeing. https:/‌/www.mentalhealthfirstaid.org/‌2019/‌07/‌four-ways-culture-impacts-mental-health/ 32 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health problems and sub- stance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well-being/‌mental-emotional -health/‌mental-emotional-health-classes-training-events/‌online-tutorial-supervisors/‌section-1-what-you-need-know-about -mental-health-problems-substance-misuse 10 Foundational Mental Health Concepts Chapter 1 Environmental Factors My Notes Individuals are affected by broad social and cultural factors, as well as by unique factors in their personal environ- ments. Social factors such as racism, discrimination, poverty, and violence (often referred to as “social determinants of health”) can contribute to mental illness. 🔗 Read more about addressing social determinants of health in the “Advocacy” chapter of Open RN Nursing Management and Professional Concepts. Additionally, it is estimated that 61% of adults have experienced early adverse childhood experiences (ACEs) such as abuse, neglect, or growing up in a household with violence, mental illness, substance misuse, incarcera- tion, or divorce. Chronic stress from ACEs can change brain development and affect how the body responds to stress. ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood.33,34 See Figure 1.235 for an image of adverse childhood experiences. Figure 1.2 Adverse Childhood Experiences (ACEs) Individual trauma resulting from an event, series of events, or set of circumstances that is experienced as physically or emotionally harmful can have lasting adverse effects on the individual’s functioning and mental, physical, social, 33 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health problems and sub- stance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well-being/‌mental-emotional -health/‌mental-emotional-health-classes-training-events/‌online-tutorial-supervisors/‌section-1-what-you-need-know-about -mental-health-problems-substance-misuse 34 National Human Trafficking Training and Technical Assistance Center. (n.d.) The original ACE study. https:/‌/nhttac.acf.hhs.gov/‌soar/‌eguide/‌stop/‌adverse_childhood_experiences 35 “ACEs.png” by unknown author for Centers for Disease Control and Prevention is licensed in the Public Domain. Ac- cess for free at https:/‌/www.cdc.gov/‌injury/‌pdfs/‌priority/‌ACEs-Strategic-Plan_Final_508.pdf 11 Nursing Mental Health and Community Concepts My Notes emotional, or spiritual well-being.36 Read more about ACEs and addressing individual trauma in the “Introduc- tion to Trauma-Informed Care” section of this chapter. 🔗 Take the Adverse Childhood Experiences Questionnaire for Adults to better understand how previous experiences can affect one’s well-being. Current stressors such as relationship difficulties, the loss of a job, the birth of a child, a move, or prolonged prob- lems at work can also be important contributory environmental factors.37 🔗 Read more about stress in the “Stress, Coping, and Crisis Intervention” chapter. Biological Factors Scientists believe the brain can have an imbalance of neurotransmitters, such as dopamine, acetylcholine, gamma- aminobutyric acid (GABA), norepinephrine, glutamate, and serotonin, resulting in changes in behavior, mood, and thought. While causes of fluctuations in brain chemicals aren’t fully understood, contributing factors can include physical illness, hormonal changes, reactions to medication, substance misuse, diet, and stress.38 🔗 Read more about neurotransmitters and the central nervous system in the “Psychotropic Medications” chapter. Some studies also suggest that depressive and bipolar disorders are accompanied by immune system dysregulation and inflammation.39 Genetics There appears to be a hereditary pattern to some mental illnesses. For example, individuals with major depressive disorder often have parents or other close relatives with the same illness. Research continues to investigate genes involved in specific disorders so that treatment can be effectively targeted to the individual.40 36 U.S. Department of Health & Human Services. (2020, January 24). Strategic goal 3: Strengthen the economic and social well-being of Americans across the lifespan. https:/‌/www.hhs.gov/‌about/‌strategic-plan/‌strategic-goal-3/‌index.html 37 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health prob- lems and substance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well- being / mental-emotional-health / mental-emotional-health-classes-training-events / online-tutorial-supervisors / section- 1-what-you-need-know-about-mental-health-problems-substance-misuse 38 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health prob- lems and substance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well- being / mental-emotional-health / mental-emotional-health-classes-training-events / online-tutorial-supervisors / section- 1-what-you-need-know-about-mental-health-problems-substance-misuse 39 Kraybill, O. (2019, May 31). Inflammation and mental health symptoms. Psychology Today. https:/‌/www.psychologytoday.com/‌us/‌blog/‌expressive-trauma-integration/‌201905/‌inflammation-and-mental-health-symptoms 40 University of Michigan Human Resources. (n.d.). Section 1: What you need to know about mental health problems and sub- stance misuse. https:/‌/hr.umich.edu/‌benefits-wellness/‌health-well-being/‌mhealthy/‌faculty-staff-well-being/‌mental-emotional -health/‌mental-emotional-health-classes-training-events/‌online-tutorial-supervisors/‌section-1-what-you-need-know-about -mental-health-problems-substance-misuse 12 Foundational Mental Health Concepts Chapter 1 🎦 My Notes View the following YouTube video on causes of mental illness41: Understanding the Biology of Mental Illness. WHO Guidelines for Mental Health Care It is vital for nurses to protect and promote the mental well-being of all individuals and address the needs of individuals with diagnosed mental disorders.42 The World Health Organization (WHO) published the Mental Health Intervention Guide for nurses and primary health care providers that provides evidence-based guidance and tools for assessing and managing priority mental health and substance use disorders using clinical decision- making protocols. Essential principles for providing mental health care include promoting respect and dignity for the individuals seeking care; using effective communication skills to ensure care is provided in a nonjudgmental, nonstigmatizing, and supportive manner; and conducting comprehensive assessments.43 Promoting Respect and Dignity Individuals with mental health and substance use conditions should be treated with respect and dignity in a culturally appropriate manner. Health care professionals should promote the preferences of people with mental health and substance use disorders and support them, their family members, and their loved ones in an inclusive and equitable manner. These are some tips discussed in the WHO Mental Health Intervention Guide44: Do: Treat people with mental health and substance use conditions with respect and dignity. Protect confidentiality. Ensure privacy. Provide access to information and explain the proposed treatment risks and benefits in writing when possible. Make sure the person provides consent to treatment. Promote autonomy and independent living in the community. Provide access to decision-making options. Don’t: Discriminate against people with mental health and substance use conditions. Ignore individual preferences. 41 Alabama Department of Health. (2011, July 29). Understanding the biology of mental illness [Video]‌. YouTube. All rights reserved. https://youtu.be / LLUoG9Se77w 42 World Health Organization. (2018, March 30). Mental health: Strengthening our response. https:/‌/www.who.int/‌news -room/‌fact-sheets/‌detail/‌mental-health-strengthening-our-response 43 mhGAP Intervention Guide - Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 44 mhGAP Intervention Guide - Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 13 Nursing Mental Health and Community Concepts My Notes Make decisions for or on behalf of individuals. Use overly technical language when explaining proposed treatment. Using Effective Communication Skills Using effective communication skills promotes quality mental health care. Tips for effective communication from the WHO Mental Health Intervention Guide include the following45: Create an Environment That Facilitates Open Communication. Meet the person in a private space, if possible. Be welcoming and conduct introductions in a culturally appropriate manner. Use culturally appropriate eye contact, body language, and facial expressions that facilitate trust. Explain to adults that information discussed during the visit will be kept confidential. (Special considerations regarding “conditional confidentiality” and mandatory reporting for minors are discussed in the “Childhood and Adolescence Disorders” chapter.) If caregivers are present, suggest speaking with the client alone (except for young children) and obtain consent from the client to share clinical information. When interviewing a young person, consider having another person present who identifies with the same gender to maintain feelings of a psychologically safe environment. Involve the Person. Include the person (and with their consent, their caregivers and family members) in all aspects of assessment and management as much as possible. This includes children, adolescents, adults, and older adults. Start by Listening. Actively listen. Be empathic and sensitive. (Read more about active listening in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.) Allow the person to speak without interruption. Be patient and ask for clarification of unclear information. For children, use language that they can understand. For example, ask about their interests (toys, friends, school, etc.). For adolescents, convey that you understand their feelings and situation. Be Friendly, Respectful, and Nonjudgmental. Always be respectful. Be nonjudgmental about an individual’s behaviors and appearances. Remain calm and professional. 45 mhGAP Intervention Guide - Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 14 Foundational Mental Health Concepts Chapter 1 Use Good Verbal Communication Skills. My Notes Use simple language. Be clear and concise. Avoid medical terminology only understood by health care professionals. Use open-ended questions and other therapeutic communication techniques. (Read more about specific techniques in the “Therapeutic Communication and the Nurse-Client Relationship” chapter.) For example: Use open-ended questions: “Tell me more about what happened?” Summarize: “So, your brother pushed you off your bike and then laughed when you fell and started crying?” Clarify: “To clarify, were you at home or a neighbor’s house when this happened?” Summarize and repeat key points at the end of the conversation. Allow the person to ask questions about the information provided. For example, “What questions do you have about what we have discussed today?” Respond With Sensitivity When People Disclose Traumatic Experiences (E.G., Sexual Assault, Violence, or Self-Harm). Thank the person for sharing this sensitive information. Show extra sensitivity when discussing difficult topics. Remind the person that what they tell you will only be shared with the immediate treatment team to provide the best possible care. Acknowledge that it may have been difficult for the person to disclose the information. Therapeutic Relationship In all nursing care, the therapeutic relationship with the client is essential. This is especially so in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing.46 Although nurse generalists are not expected to perform advanced psychiatric interventions, all nurses are expected to engage in compassionate, supportive relationships with their patients and use therapeutic communication as part of the “art of nursing.”47 The nurse-client relationship establishes trust and rapport with a specific purpose. It facilitates therapeutic com- munication and engages the client in decision-making regarding their plan of care. Read more about therapeutic communication and the nurse-client relationship in the “Therapeutic Communication and the Nurse-Client Relationship” chapter. 46 Ross, C. A., & Goldner, E. M. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 16(6), 558-567. https:/‌/doi.org /‌10.1111/‌j.1365-2850.2009.01399.x 47 Centers for Disease Control & Prevention. (2021, July 22). Coping with stress. https:/‌/www.cdc.gov/‌mentalhealth/‌stress -coping/‌cope-with-stress/‌index.html 15 Nursing Mental Health and Community Concepts My Notes Conducting Comprehensive Assessments Clients undergo comprehensive assessments related to their disorder, including mental status examination, psy- chosocial assessment, physical examination, and review of laboratory results. Specific nursing assessments are further discussed in the “Application of the Nursing Process in Mental Health Care” chapter, as well in each “Disorder” chapter. Persons with severe mental health and substance use disorders are two to three times more likely to die of preventable disease like infections and cardiovascular disorders, so it is also important for nurses to advocate for the medical treatment of existing physical disorders.48 🔗 View the WHO’s Mental Health Gap Intervention Guide. 48 mhGAP Intervention Guide - Version 2.0 by World Health Organization is licensed under CC BY-NC-SA 3.0 16 Foundational Mental Health Concepts Chapter 1 1.3 INTRODUCTION TO TRAUMA-INFORMED CARE My Notes Many individuals experience trauma during their lifetimes that can have a lasting impact on their mental health. Trauma results from an event, series of events, or set of circumstances that are experienced by an individual as physically or emotionally harmful and can have lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. Events may be human-made, such as war, terrorism, sexual abuse, vio- lence, or medical trauma, or they can be the products of nature (e.g., flooding, hurricanes, and tornadoes). Nurses must keep in mind to not interject their own experiences or perspectives because something minor to them may be major to the client. It’s not just the event itself that determines if it is traumatic, but the individual’s experience of the event. Two people may be exposed to the same event or series of events but experience and interpret these events in vastly different ways. Various biopsychosocial and cultural factors influence an individual’s immediate response and long- term reactions to trauma. For most individuals, regardless of the severity of the trauma, the effects of trauma are met with resilience, defined as the ability to rise above circumstances or meet challenges with fortitude. Resilience includes the process of using available resources to negotiate hardship and / or the consequences of adverse events.1 Trauma can affect people of any culture, age, gender, or sexual orientation. Individuals may also experience trauma even if the event didn’t happen to them. A traumatic experience can be a single event, a series of events, or adverse childhood experiences (ACEs). Review information about ACEs in the “Mental Health and Mental Illness” sec- tion of this chapter. There has been an increased focus on the ways in which trauma, psychological distress, quality of life, health, mental illness, and substance misuse are linked. For example, the terrorist attacks of September 11, 2001, the wars in Iraq and Afghanistan, disastrous hurricanes, and the COVID pandemic have moved traumatic experiences to the forefront of national consciousness. Trauma can affect individuals, families, groups, communi- ties, specific cultures, and generations. It can overwhelm an individual’s ability to cope; stimulate the “fight, flight, or freeze” stress reaction; and produce a sense of fear, vulnerability, and helplessness.2 🔗 Read more information about the stress reaction in the “Stress, Coping, and Crisis Intervention” chapter. For some people, reactions to a traumatic event are temporary, whereas other people have prolonged reactions to trauma with enduring mental health consequences, such as post-traumatic stress disorder, anxiety disorder, substance use disorder, mood disorder, or psychotic disorder. Others may exhibit culturally mediated physical symptoms referred to as somatization, in which psychological stress is expressed through physical concerns such as chronic headaches, pain, and stomachaches. Traumatic experiences can significantly impact how an individual functions in daily life and how they seek medical care.3 Individuals may not recognize the significant effects of trauma or may avoid the topic altogether. Likewise, nurses may not ask questions that elicit a client’s history of trauma. They may feel unprepared to address trauma-related 1 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 2 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 3 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 17 Nursing Mental Health and Community Concepts My Notes issues proactively or struggle to effectively address traumatic experiences within the constraints of their agency’s policies.4 By recognizing that traumatic experiences are closely tied to mental health, nurses can provide trauma-informed care and promote resilience. Trauma-informed care (TIC) is a strengths-based framework that acknowledges the prevalence and impact of traumatic experiences in clinical practice. TIC emphasizes physical, psychological, and emotional safety for both survivors and health professionals and creates opportunities for survivors to rebuild a sense of control and empowerment (i.e., resilience).5 TIC acknowledges that clients can be retraumatized by unexamined agency policies and practices and stresses the importance of providing patient-centered care rather than applying general treatment approaches.6 TIC enhances therapeutic communication between the client and the nurse. It decreases risks associated with misunderstanding clients’ reactions or underestimating the need for referrals for trauma-specific treatment. TIC encourages patient-centered care by involving the client in setting goals and planning care that optimizes thera- peutic outcomes and minimizes adverse effects. Clients are more likely to feel empowered, invested, and satisfied when they receive TIC.7 Implementing TIC requires specific training, but it begins with the first contact a person has with an agency. It requires all staff members (e.g., receptionists, direct patient-care staff, nurses, supervisors, and administrators) to recognize that an individual’s traumatic experiences can greatly influence their receptivity and engagement with health services. It can affect their interactions with staff, as well as their responsiveness to care plans and interventions.8 🎦 View the following YouTube video on trauma-informed approach to health care9: Dr. Pickens Explains Trauma-Informed Approach. 🔗 Read more details about trauma-informed care (TIC) in the “Trauma, Abuse, and Violence” chapter. 4 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 5 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 6 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 7 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 8 Center for Substance Abuse Treatment (US). (2014). Trauma-informed care in behavioral health services. https:/‌/www.ncbi.nlm.nih.gov/‌books/‌NBK207201/ 9 Washington State Health Care Authority. (2019, June 24). Dr. Pickens explains trauma-informed approach [Video]‌. You- Tube. All rights reserved. https://youtu.be / 6syEFO4OSFU 18 Foundational Mental Health Concepts Chapter 1 1.4 STIGMA My Notes Despite a recent focus on mental health in the United States, there are still many harmful attitudes and misun- derstandings surrounding mental illnesses that can cause people to ignore their mental health and make it more difficult for them to reach out for help.1,2 Stigma has been defined as a cluster of negative attitudes and beliefs that motivates the general public to fear, reject, avoid, and discriminate against people with mental health disorders.3 It estimated that nearly two thirds of people with diagnosable mental health disorders do not seek treatment due to the stigma of mental illness. The U.S. Surgeon General’s Report in 1999 was a

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