Introduction to Psychiatric / Mental Health Nursing

Philosophy and Theories for Interdisciplinary Psychiatric Care

Chapter 1, 2 & 5

West Coast UniversityNURSING 204

Caring for Psychiatric Mental Health Clients

Feelings, Concerns, Questions—What Are They?

Who Are They?

People with Mental Illness

Factors Influencing Expectations

Expectations

Media

Upbringing Other?

Life experiencesCulture

Psychiatric Mental Health Clients

Psychiatric mental health clients are everyday, ordinary people.

Removing the stigma of Mental IllnessDefinition of Stigma: a mark of disgrace or infamy;

a stain or reproach, as on one’s reputationBest defined as ignorance, prejudice and

discrimination

Factors Impacting Mental Health and Mental Illness

Mental Illness

Biological

Social Cultural

Mental Health

or

What do these terms mean?

Berserk? Crazy?

Insane?

Nervous Breakdown?

Lunatic ?

Melancholy?

Wacky?

Weird?

Historical ApproachesEra of Magico-Religious Explanations

Era of Organic Explanations (4th Century)

Era of Alienation (1300 – 1600)

Era of Confinement (17th Century)

Era of Moral Treatment (18th – 19th Century) Reform leaders:

William CullenPhilippe PinelWilliam TukeBenjamin FranklinBenjamin Rush “Father of American Psychiatry”

A ward in Bethlehem Hospital about 1745. A patient is being chained in the foreground, and in the background are two Sunday visitors on an

entertainment outing. Source: Philosophical Library.

Historical Approaches - continued

Era of Psychoanalysis (19th to 20th Century)Sigmund Freud

Contemporary Developments (mid 20th Century)Social dimensionsBrain dysfunctionNeurochemicalMedication therapy

21st Century ResearchBases for mental disorders

Psychotropic medications

Role of nutrients, biology, and genetics

Mental Disorder StatisticsHigh incidence with physical illness

Account for 47% of all disability in economically developed countries

Account for 28% of all disability worldwide

Mental Illness Characteristics

Distress

Disability

Risks

Prevalence Rates for Various Mental Disorders

Leading Causes of Mental Disability Worldwide

Mental Health StudiesEpidemiologic Catchment Area (ECA)

Global Burden of Disease (WHO)

U.S. Surgeon General’s Report

Healthy People 2020

Healthy People 2020Reduce suicide rate

Reduce the rate of suicide attempts by adolescents

Increase services for homeless adults with serious mental illness (SMI)

Reduce relapse with eating disorders in adolescents

Increase mental health screening in primary care services

Increase mental health services in children

Healthy People 2020 - continued

Screening in juvenile justice

Track consumers’ satisfaction with mental health services

Jail diversion programs for SMI

Cultural competency

Plan that address specialized mental health services for the elderly persons.

Increase services for person with co-occurring substance abuse and SMI

Employee stress in the workplace

Psychiatric-Mental Health Nurses

What do they do?

Chapter 2

StandardsStandards of Psychiatric-Mental Health Nursing

Practice:Guidelines for providing quality care

Psychiatric-Mental Health Nursing Standards of Practice1.Assessment2.Diagnosis3.Outcomes Identification4.Planning

Standards - continuedPsychiatric-Mental Health Nursing Standards of

Practice5. Implementation

A.Coordination of CareB.Health Teaching and Health PromotionC.Milieu TherapyD.Phamacological, Biological, and Integrative

TherapiesE.Prescriptive Authority and Treatment (APRN only)F.Psychotherapy (APRN only)G.Consultation (APRN only)

6.Evaluation

Standards - continuedStandards of Professional Performance

7.Quality of Practice

8.Education

9.Professional Practice Evaluation

10.Collegiality

11.Collaboration

12.Ethics

13.Research

14.Resource Utilization

15.Leadership

Psychiatric-Mental Health Nurses

Generalist level

Advanced practice levelPrescriptive authorityPsychotherapyConsultation

Estimated Number of Mental Health Workers in the United States

The Mental Health Team

Effective Mental Health Services

Partnerships

Client

PMH Team Family

Lessons on Collaboration “Know thyself”

Value diversity

Know that conflict is natural

Share your power with others

Master communication skills

Think life-long learning.

Embrace interdisciplinary situations.

Appreciate spontaneity.

Balance unity with autonomy.

The Role of the Psychiatric-Mental Health Nurse

MultifacetedCustodial

Psychiatric-Mental Health Nursing (1940-1990)

Nurses begin to educate nurses.

Psychiatric theory includes interpersonal and emotional dimensions.

National Mental Health Act of 1946

Elimination of single-focus psychiatric nursing schools

Period of role clarification

Hildegard Peplau

Gwen Tudor

Frances Sleeper

Community Mental Health Centers Act of 1963

Psychiatric nursing journals

Psychiatric-Mental Health Nursing (1940-1990) - continued

Birth of clinical nurse specialists and nurse therapist role

First standards of psychiatric-mental health nursing practice

Increase role of nurses at national level

Shift in psychiatric nursing toward humanistic interactionism

Decrease in numbers of psychiatric nurses

Decreased funding for training

Psychiatric nursing diagnoses

Psychiatric-Mental Health Nursing (1990s) - Decade of the Brain

Psychobiologic concepts

Nursing Psychopharmacology Project

Health care delivery reform

Outcome-based research

Cultural diversity

Integration of theoretical perspectives

Psychiatric-Mental Health Nursing (2000s) - The New Millennium

Standards of practice – revisions

Knowledge explosion

Renewed focus on physical health

Single point of entry

Advanced practice nurses

Expansion of practice settings

Nursing Theories Impacting Psychiatric Nursing

Marjory Gordon – Functional Health Patterns (1987)

Hildegard Peplau – Interpersonal Relationships (1952)

Dorothea Orem – Self-Care Deficit (1959)

Dorothy Johnson – Behavioral System (1968)

Sister Callista Roy – Adaptation Model (1976)

Hildegard Peplau, PhD, RN, FAAN

Marjory Gordon ,PhD, RN, FAAN

Nursing Theories - ValueNursing practice vs. medical practice

Caring vs. curing

Interpretation of meaning

Nurse-client relationship

Advocacy of client dignity

Advocacy of nurse authenticity

Application of Theoretical Frameworks

Application of various theoretical frameworks leads to: Quality client-centered care.Efficient use of resources.Practice-oriented research.Clinical judgments and actions that can be

articulated and taught to others.

Gordon's 11 Functional Health Patterns

FunctionalHealth Pattern

Pattern Describes Examples

Health Perception/Health Management

Client's perceived pattern of health and well-being and how health is managed.

Compliance with medication regimen, use of health-promotion activities such as regular exercise, annual check-ups.

Nutritional-Metabolic Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply.

Condition of skin, teeth, hair, nails, mucous membranes; height and weight.

Elimination Patterns of excretory function (bowel, bladder, and skin). Includes client's perception of a “normal" function.

Frequency of bowel movements, voiding pattern, pain on urination, appearance of urine and stool.

Activity - Exercise Patterns of exercise, activity, leisure, and recreation.

Exercise, hobbies. May include cardiovascular and respiratory status, mobility, and activities of daily living.

Cognitive-Perceptual Sensory-perceptual and cognitive patterns.

Vision, hearing, taste, touch, smell, pain perception and management; cognitive functions such as language, memory, and decision making.

Sleep-Rest Patterns of sleep, rest, and relaxation.

Client's perception of quality and quantity of sleep and energy, sleep aids, routines client uses.

Gordon's 11 Functional Health Patterns

FunctionalHealth Pattern

Pattern Describes Examples

Role-Relationship Client's pattern of role engagements and relationships.

Perception of current major roles sand responsibilities (e.g., father, husband, salesman); satisfaction with family, work, or social relationships.

Sexuality-Reproductive Patterns of satisfaction and dissatisfaction with sexuality pattern; reproductive pattern.

Number and histories of pregnancy and childbirth; difficulties with sexual functioning; satisfaction with sexual relationship.

Coping / Stress Tolerance General coping pattern and effective of the pattern in terms of stress tolerance.

Client's usual manner of handling stress, available support systems, perceived ability to control or manage situations.

Value - Belief Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions.

Religious affiliation, what client perceives as important in life, value-belief conflicts related to health, special religious practices.

Self-Perception/Self Concept

Client's self-concept pattern and perceptions of self.

Body comfort, body image, feeling state, attitudes about self, perception of abilities, objective data such as body posture, eye contact, voice tone.

Holistic Practice:Expanded Role for Nurses (Chapter 5)

InteractionismIndividuals have purpose and control.Humanistic castInteraction of psychology, psychobiology, and

sociocultural contexts

HumanismDevotion to individual interestsSpirit of compassion and caringAffirming of the joy, beauty, and value of living

Nursing Implications Humanistic Interactionism

Interrelated physical and mental factorsHolisticExpanded role for psychiatric-mental health nurses

Client and family role includes negotiation and advocacy.

Nursing ImplicationPsychobiology

Focus on biological, medical, and human aspects of care.

HolisticIntegrative

New knowledge“High tech” and “high touch” Nature and nurtureBiologic sciences and behavioral sciences

Medical-Psychobiologic Theory

Key concepts

Emotional disturbance indicates illness or defect.

Illnesses are located in the brain or central nervous system.

Illnesses have specific characteristics.Mental diseases have a characteristic course.Mental disorders respond to physical or somatic

treatments.Psychobiologic explanations reduce stigma.

Comparison of Traditional Psychiatric Theories

Psychoanalytic TheorySigmund Freud:

All psychological emotional events can be understood.

Childhood experiences → adult neuroses

Goal of therapy is gaining insight.

Psychoanalytic Theory

Levels of awareness in relation to id, ego, and superego

Id: Present at birth. Serves to satisfy needs and immediate gratification

Ego: Begins to develop at 4 – 6 months. Maintain contact with reality,

rational part of personality.

Superego: begins to develop at about 3 – 6 years. Serves as conscience

(sense of right or wrong)

Cognitive Concepts

Social–Interpersonal Theories

Social–Interpersonal Theories

Maslow: Self-Actualization and Hierarchy of Needs