Mental Health Nursing Concepts - Definitions, Barriers, and Care

**1. Unique Challenges to Accessing Psychiatric Care** - **Lack of Awareness or Information**: Limited knowledge, misunderstanding of symptoms, psychiatric disorders affecting recognition of care needs. - **Stigma and Social Attitudes**: Fear of judgment, discrimination, internaliz...

**1. Unique Challenges to Accessing Psychiatric Care** - **Lack of Awareness or Information**: Limited knowledge, misunderstanding of symptoms, psychiatric disorders affecting recognition of care needs. - **Stigma and Social Attitudes**: Fear of judgment, discrimination, internalized stigma. - **Systemic and Structural Barriers**: Fragmentation of care, lack of coordination between providers. **2. Brief History of Psychiatric Care in the U.S.** - **1700s**: Asylums established, became overpopulated. - **1800s**: Psychiatric nursing began in Massachusetts. - **1950s**: First antipsychotic medication (Thorazine). - **1960s**: Medicare/Medicaid created, but no psychiatric funding. - **1999**: Olmstead Decision led to deinstitutionalization. - **2016**: Drop in state psychiatric hospitals. **3. Continuum of Care** - **Outpatient Care Settings**: Primary care, community clinics, telehealth. - **Emergency Care Models**: Crisis stabilization units, psychiatric emergency services. - **Prevention in Outpatient Care**: Education, screenings, community programs. **4. Case Study: Edgar** - **Diagnosis**: Major Depression, PTSD. - **Treatment Approach**: Patient-centered medical home, collaboration. - **Prevention Type**: Secondary prevention (early intervention). **5. Inpatient Care Settings** - **Hospitalization Criteria**: Safety concerns, inability to self-care. - **Types of Inpatient Facilities**: - Crisis Stabilization Units (CSU) - General Hospitals - Private Hospitals - State Psychiatric Hospitals (long-term care, forensic populations) - **Patient Rights**: Retain civil rights, informed consent required unless in emergencies. - **Team Collaboration**: Multidisciplinary planning, clinical pathways. **6. Inpatient Psychiatric Nursing Roles** - Data collection, care planning, crisis management. - Ensuring safety, facilitating health education. - Coordination with healthcare teams. **7. Discharge Considerations** - Housing, income, support system, substance use, physical well-being. **8. Specialty Treatment Settings** - **Pediatric and Geriatric Psychiatry** - **Veteran's Administration Centers** - **Forensic Psychiatric Care**: High prevalence of mental illness in incarcerated populations. - **Substance Use Disorder Treatment** **Key Cultural Concepts in Mental Health Nursing** **1. Definitions to Know** - **Minority:** A group with fewer members or less power in society. - **Race:** Defined by physical characteristics; biological, anthropological, or genetic distinctions. - **Ethnicity:** Shared heritage, history, and worldview. - **Culture:** Shared beliefs, values, and practices influencing behavior and perception of illness. **2. Importance of Culturally Relevant Care** - Reduces disparities in mental healthcare. - Helps establish trust and effective communication. - Ensures treatments align with patients' beliefs and values. **3. Cultural Differences in Healthcare Beliefs** **Tradition** **Identity Source** **Mind-Body View** **View of Disease** **Concept of Time** ---------------- --------------------- ------------------------------------- ------------------------------------- ------------------------- **Western** Individuality Mind & body separate Disease has a specific cause Linear (future-focused) **Eastern** Family-based Mind-body-spirit connected Disease caused by energy imbalances Cyclical **Indigenous** Tribal identity Person connected to the environment Disease is disharmony with nature Holistic time view **4. Cultural Barriers to Mental Health Care** - **Communication barriers:** Language differences can lead to misinterpretation. - **Stigma of mental illness:** Some cultures view mental illness as shameful. - **Misdiagnosis:** Symptoms may be expressed differently across cultures. - **Genetic variations in pharmacodynamics:** Medication responses can differ by ethnicity. **5. Cultural Concepts of Distress** - **Culture-bound syndromes:** Disorders recognized only within specific cultures. - **Cultural idioms of distress:** Expressions of distress unique to a culture. - **Cultural explanations of illness:** How a culture interprets the cause of mental illness. **6. At-Risk Populations** - **Immigrants:** Move voluntarily for better opportunities. - **Refugees:** Flee due to intolerable conditions. - **Cultural minorities:** Often face discrimination and limited access to healthcare. **7. Culturally Congruent Care** **Five Constructs of Culturally Effective Care:** 1. **Cultural Awareness:** Recognizing personal biases. 2. **Cultural Knowledge:** Learning about different cultures. 3. **Cultural Encounters:** Engaging with diverse patients. 4. **Cultural Skill:** Conducting culturally sensitive assessments. 5. **Cultural Desire:** A genuine willingness to understand and care for diverse patients. **Legal and Ethical Considerations in Psychiatric Nursing** **1. Key Ethical Concepts** - **Ethics:** Study of right and wrong in society. - **Bioethics:** Ethical dilemmas in healthcare. - **Ethical dilemma:** Conflict between two justifiable courses of action. **Five Principles of Bioethics** 1. **Beneficence:** Promote good. 2. **Autonomy:** Respect patients\' decisions. 3. **Justice:** Fair distribution of resources and care. 4. **Fidelity (Nonmaleficence):** Maintain loyalty, do no harm. 5. **Veracity:** Be truthful with patients. **2. Mental Health Laws & Admission Procedures** **Types of Admissions** - **Informal Admission:** Patient seeks treatment voluntarily. - **Voluntary Admission:** Patient or guardian requests admission. - **Involuntary Commitment:** Without patient consent if they are: - Mentally ill - Danger to self/others - Unable to meet basic needs **Involuntary Commitment Types** - **Emergency Commitment:** 24-96 hours for evaluation. - **Assisted Outpatient Treatment:** Court-ordered outpatient care. **Due Process in Involuntary Commitment** - **Writ of Habeas Corpus:** Patient can challenge unlawful detention. - **Least Restrictive Alternative Doctrine:** Use the least restrictive means for treatment. **3. Discharge Procedures** - **Conditional Release:** Ongoing outpatient treatment required. - **Unconditional Release:** Complete discharge from care. - **Release Against Medical Advice (AMA):** Patient leaves despite medical recommendations. **4. Patients' Rights** - **Right to Treatment:** Cannot be denied care. - **Right to Refuse Treatment:** Includes medication (unless legally overridden). - **Right to Informed Consent:** Patients must understand risks, benefits, and alternatives before treatment. - **Rights Regarding Restraint & Seclusion:** - Use only when necessary. - Follow legal & ethical guidelines. **5. Confidentiality in Psychiatric Care** - **HIPAA:** Protects patient privacy. - **Confidentiality After Death:** Rights continue after the patient passes. - **Confidentiality in Professional Communication:** Protects provider-patient interactions. - **Confidentiality & HIV Status:** Legal protections apply. **Exceptions to Confidentiality** - **Duty to Warn & Protect:** Required if patient poses a threat to others. - **Mandated Reporting:** Must report child and elder abuse. **6. Legal Concerns in Psychiatric Nursing** **Tort Law (Civil Wrongs)** - **Intentional Torts:** - **Assault:** Threat to harm. - **Battery:** Unwanted physical contact. - **False Imprisonment:** Unjustified restriction of movement. - **Invasion of Privacy:** Unauthorized sharing of personal information. - **Defamation (Slander/Libel):** False statements harming reputation. - **Unintentional Torts:** - **Negligence:** Failing to act reasonably. - **Malpractice:** Professional negligence leading to harm. **Elements of Negligence** 1. **Duty:** Nurse owed care. 2. **Breach of Duty:** Standard of care not met. 3. **Cause in Fact:** Direct link between breach and harm. 4. **Proximate Cause:** Harm was foreseeable. 5. **Damages:** Patient suffered harm or injury. **7. Standards of Nursing Care & Documentation** - **Governed by:** - Nurse Practice Acts - Professional Organizations (APA, APNA) - Institutional Policies - **Duty to Report:** - Negligence - Impairment (drug/alcohol use) - Criminal activity **Documentation Guidelines** - Ensure accuracy and completeness. - Used for legal protection and quality improvement. - Electronic records are increasingly common. **8. Forensic Nursing & Violence Prevention** - **Forensic Nursing:** Assists courts in psychiatric cases. - **Violence in Psychiatric Settings:** - Nurses must document risks. - Report threats to colleagues. - Employers are not liable for injuries from violent patients. **Main Models of Modern Family Therapy** Family therapy can be broadly categorized into several models, each with unique goals and methodologies. Below is an in-depth look into these primary paradigms. **Insight-Oriented Family Therapy** **Focus**: Developing increased awareness among family members regarding themselves, others, and their family unit. - **Approach**: Encourages insight and emotional understanding. - **Examples**: Psychodynamic and humanistic family therapies. **Behavioral Family Therapy** **Focus**: Changing behaviors to influence overall family interaction patterns. - **Approach**: Uses reinforcement, modeling, and other behavior modification techniques. - **Examples**: Cognitive-behavioral therapy (CBT), operant conditioning. **Contextual Therapy** **Goal**: Gain insight into problematic relationships. - **Approach**: Focuses on ethical dimensions of family interactions and fairness. **Family of Origin Therapy** **Goal**: Foster differentiation and decrease emotional reactivity. - **Approach**: Identifies patterns rooted in the family of origin that affect current functioning. **Experiential-Existential Therapy** **Goal**: Guide the family to identify and develop their own solutions to dysfunctional behavior. - **Approach**: Emphasizes authenticity and self-expression within family units. **Structural Therapy** **Goal**: Improve family relationships by restructuring family hierarchy and boundaries. - **Approach**: Examines and modifies the organization of the family system. **Strategic Therapy** **Goal**: Realign family hierarchy through the use of rituals to change repetitive and maladaptive patterns. - **Approach**: Uses strategies and directives to initiate change. **Cognitive-Behavioral Therapy (CBT)** **Goal**: Improve patterns of negative behaviors through changing thought patterns. - **Approach**: Cognitive restructuring to correct distorted thinking. **Goals of Family Therapy** Family therapy seeks to achieve various objectives, depending on the specific needs of the family and the chosen therapeutic model. - **Improve Individual Skills**: Enhance coping and problem-solving abilities of family members. - **Strengthen Family Functioning**: Foster resilience, cohesion, and healthy interaction patterns as a whole. - **Reduce Dysfunctional Behavior**: Correct maladaptive behaviors and resolve conflicts. - **Mobilize Family Resources**: Encourage adaptive problem-solving behaviors and improve communication skills. - **Increase Emotional Support**: Heighten awareness of each other\'s emotional needs and foster a supportive environment. **Core Concepts in Family Therapy** **Identified Patient** The family member regarded as the symptomatic problem, whose behaviors and issues initiate the need for therapy. Often, the problems exhibited by this individual reflect broader family dynamics. **Family Triangles** Occurs when one family member communicates indirectly with another family member through a third member, creating a triangulated relationship that can perpetuate issues. **Boundaries** Refers to the rules and roles within the family system that dictate how members interact: - **Clear Boundaries**: Healthy balance, where members maintain individuality while supporting each other. - **Diffuse or Enmeshed Boundaries**: Excessive communication, leading to loss of autonomy. - **Rigid or Disengaged Boundaries**: Lack of communication, leading to isolation. **Assessment Tools in Family Therapy** **Sociocultural Assessment** Analyzes the family in its sociocultural context, considering factors such as ethnicity, socioeconomic status, and cultural norms. **Genogram** A structured family tree depicting relationships, medical histories, and significant events across three generations, helping to identify patterns and issues. **Application of Nursing Process in Family Therapy** **Family Assessment** Involves understanding the family\'s dynamics, cultural context, and specific issues through various tools and techniques. **Nursing Interventions** - **Communication Techniques**: Promote open dialogue. - **Counseling**: Address stress indicators and provide treatment education. - **Advanced Practice Interventions**: Conduct specialized family therapy and manage pharmacological interventions. **Characteristics of a Healthy Family** - **Safety and Support**: Providing a secure environment and robust support systems. - **Effective Communication**: Clear, open, and respectful interactions. - **Proper Boundaries**: Balanced rules that support individuality and togetherness. - **Emotional Support**: Showing empathy, care, and understanding. - **Socialization**: Teaching social norms, values, and adaptive behaviors. **H1: Therapeutic Nursing Relationships** **Key Concepts Central to Nurse-Patient Relationships** - **Patient-Centered Care**: Emphasizes dignity, respect, information sharing, patient and family participation, and collaboration in policy development. - **Therapeutic Use of Self**: Involves the intentional use of personal attributes to establish patient trust and engagement. **Goals and Functions of Therapeutic Relationships** - Facilitating communication of distressing thoughts and feelings. - Assisting patients with problem solving. - Examining self-defeating behaviors and testing alternatives. - Promoting self-care and independence. - Providing education about disorders and treatments. **Building Healthy Relationships** - Assessing patient needs and unmet needs. - Implementing de-escalation strategies. - Differentiating between personal and therapeutic relationships: - **Personal Relationships**: Based on mutual needs, socialization, friendship, and superficial communication. - **Therapeutic Relationships**: Focus on patient needs, clinical competence, and appropriate boundaries. **H2: Necessary Behaviors for Nurses** - **Accountability**: Ensuring responsibility for one\'s actions in patient care. - **Focus on Patient Needs**: Maintaining patient-centric communication. - **Clinical Competence**: Staying informed and skilled in nursing practices. - **Delaying Judgment**: Avoiding premature conclusions about patients. - **Supervision**: Seeking and providing professional oversight and guidance. **H2: Relationship Boundaries and Roles** **Importance of Boundaries** - Protect legal, ethical, and professional standards. - Create a safe space for patient exploration of feelings and treatment concerns. **Risks of Over-Involvement** - **Boundary Crossings**: Minor deviations from professional boundaries. - **Boundary Violations**: Severe issues potentially leading to patient harm. - **Professional Sexual Misconduct**: Inappropriate intimate interactions. - **Blurring of Roles**: When nurse's role shifts from professional to personal. **H2: The Phases of Nurse-Patient Relationships** **Peplau's Model** 1. **Preorientation Phase**: - Preparing for patient engagement by researching history and setting ground rules. 2. **Orientation Phase**: - Establishing rapport, setting relationship parameters, confidentiality, and terms of termination. 3. **Working Phase**: - Maintaining the relationship, gathering further data, and promoting problem-solving skills and self-esteem. - Facilitating behavioral change and overcoming resistance. 4. **Termination Phase**: - Summarizing and evaluating the patient's progress and institutionalizing learned behaviors. **Factors Promoting Patient Growth** - **Genuineness**: Being authentic in interactions. - **Empathy**: Understanding the patient\'s perspective without sympathy. - **Positive Regard**: Respectful and non-judgmental attitude. - **Attending**: Active listening skills. - **Suspending Value Judgments**: Avoiding personal bias. **H1: Therapeutic Communication** **Theories and Models** - **Transactional Model**: Emphasizes the active exchange between sender and receiver. It includes: - **Clarity**: Ensures the message is accurately understood. - **Continuity**: Fosters connected ideas, feelings, and events. - **Feedback**: Confirmation and interpretation of the message received. **Personal and Environmental Factors** - **Personal Factors**: Depression, cognition, and cultural barriers can impact communication. - **Environmental Factors**: The setting and relationship dynamics play a critical role. **Verbal and Nonverbal Communication** - **Verbal Communication**: Utilizes words to express beliefs, values, and meanings which can convey interest, judgment, or honesty. - **Nonverbal Communication**: Uses body language, facial expressions, and other non-verbal cues, often communicating more than words alone. **Double-Bind Messages** - Mutually contradictory messages that are difficult to address, often given by individuals in power positions. **Barriers to Effective Communication** - Arguing, minimizing patient concerns, false reassurance, probing, and joining in negative behavior against others should be avoided. **H2: Age and Cultural Considerations** **Age-Specific Approaches** - Children, adolescents, and older adults require different communication strategies and assessment (recognition of cues) approaches. **Cultural Sensitivity** - Communication styles, eye contact, and perceptions of touch vary significantly across cultures. Understanding cultural filters is essential to avoid bias. **H2: Nursing Process and Standards of Care** **Standards Explanation** 1. **Assessment**: Recognizing cues through systematic data collection, including mental health status and psychosocial evaluations. 2. **Diagnosis** (Hypothesis): Defining the problem, its probable cause, and symptoms. 3. **Outcomes Identification**: Setting realistic and patient-centric health outcomes. 4. **Planning**: Setting individualized care plans based on evidence-based practices. 5. **Implementation**: Executing the care plan through coordination of care, health teaching, and therapy. 6. **Evaluation**: Continuously assessing the effectiveness of the interventions, documenting outcomes, and revising plans as necessary. **Objectives in Behavioral Health Nursing** - **Assessment Approaches**: Tailor assessments for children, adolescents, and older adults. - **Language Barriers**: Differentiate between interpreters and translators in assessments. - **Mental Status Examination (MSE)**: Conduct comprehensive MSEs. - **Psychosocial Assessments**: Incorporate cultural and spiritual components into assessments. **Quality and Safety Education in Nursing (QSEN) Competencies** Nursing competencies are framed around six core areas: 1. **Patient-Centered Care**: Focus on individual patient needs and preferences. 2. **Teamwork and Collaboration**: Work efficiently within multidisciplinary teams. 3. **Evidence-Based Practice (EBP)**: Utilize current, relevant research to inform clinical decisions. 4. **Quality Improvement**: Continuously seek ways to enhance patient care. 5. **Safety**: Prioritize patient safety in all nursing activities. 6. **Informatics**: Use information technology to support and improve care. **Nursing Process and Standards of Care** **1. Assessment (Recognizing Cues)** - **Age Considerations**: Tailor assessments to children, adolescents, and older adults. - **Language Barriers**: Use appropriate resources to communicate with non-English speaking patients. - **Data Gathering**: Use reviews of systems, laboratory reports, and mental status exams to collect data. Include psychosocial, spiritual, cultural, and social assessments. - **Example**: Assessing a patient (Mr. R) with early-stage Alzheimer\'s involves recognizing recent weight loss and disease progression signs. **2. Diagnosis (Hypothesis)** - **Components of a Diagnosis**: - Problem (unmet need) - Etiology (probable cause) - Supporting data (signs and symptoms) - Example: \"Risk for suicide related to stating \'I want to kill myself\'\". **3. Outcomes Identification** - **Outcome Criteria**: Reflect the maximum level of health that can be achieved through nursing interventions. - **Nursing Outcomes Classification (NOC)**: Utilize NOC to evaluate the effects of nursing interventions through specific indicators. **4. Planning** - **Planning Principles**: Ensure the care plan is safe, compatible, appropriate, realistic, and individualized. - **Nursing Interventions Classification (NIC)**: Utilize NIC to plan evidence-based interventions. **5. Implementation (Taking Action)** - **Basic Interventions**: - Coordination of care - Health teaching and promotion - Milieu therapy - Pharmacological, biological, and integrative therapies - **Advanced Practice Interventions**: - Prescriptive authority and treatment - Psychotherapy - Consultation. **6. Evaluation (of Outcomes)** - **Continuous Evaluation**: Systematic, ongoing, and criteria-based evaluation of outcomes. - **Documentation**: Accurate and thorough documentation is crucial. Record patient conditions, treatments, responses, and any incidents to provide a legal medical record. **Practical Application through Case Studies** **Case Study: Mr. R\'s Early-Stage Alzheimer\'s** - **Scenario**: Mr. R exhibits weight loss and forgets to eat. This observation would fit into the \"Assessment\" phase as recognizing cues. - **Intervention Example**: Offering snacks and finger foods frequently as part of the intervention to manage his nutritional needs. - **Teaching and Evaluation**: After teaching Mr. R\'s sister about self-management strategies for his new prescription, her understanding would be evaluated under the \"Evaluation\" phase of the nursing process.