Orientation and Foundations of Psychiatric Mental Health Nursing

1. Orientation and Foundations of Psychiatric Mental Health Nursing 

2. Definition of Psychiatric Mental Health Nursing: A specialty within the nursing profession that focuses primarily on the use of therapeutic interpersonal interactions and biologic and interpersonal interventions with clients. PMHN focuses on human aspects and responses to illness and is therefore part of all areas of nursing.

3. Four Core Mental Health Practice Areas: Psychiatric nursing Psychiatry Psychology Social work

4. Professional attributes of psychiatric nurses include: Promotion of mental health Prevention and treatment of mental disorders Rehabilitation after the disorder

5. Historical Overview of Psychiatry

6. Prior to the 19th century, practitioners would say that mentally ill patients had �idiocy�; most treatments were cruel and inhumane Police took people to �madhouses��a private boarding home without legal or therapeutic guidelines to govern care At the end of the 19th century, private and public psychiatric hospitalizations began providing mostly custodial care The 1950�s saw the advent of new meds that revolutionalized the treatment and decreased the number of hospitalized patients

7. 1960s- Deinstitutionalization In 1963, President Kennedy decided that you couldn�t institutionalize. The goal of deinstitutionalization was to �replace the cold mercy of custodial isolation with the open warmth of community concern and capability.� This shifted the emphasis of mental health care from hospitals to community mental health centers.

8. 1970s-1990s Discovery of neurobiological factors influencing mental disease The decade of the 1990s was named by Congress as the �Decade of the Brain� Proliferation of newer biochemical therapies effective in treating mental disorders Expanding scientific technology-MRI, CT, and PET scans

9. The Millennium and Beyond Shorter hospital stays secondary to economic pressures from managed care Care today emphasizes community-linked care Development of new indications for the antidepressant medications Continued investigation of the brain and neurotransmitters

10. Concept of Nature vs Nurture Psych d/os formerly were thought to rise from some disruption in early life experiences Rigid toilet training led to unrelenting thoughts and behaviors like repeated hand washing (OCD) Later a new wave of theories of causation then emerged Biologic and genetic factors accounted for the sx of psychiatric illness, i.e., people were manic depressive not because of poor parenting or difficulty in childhood but because of their genetic makeup

11. Concept of Nature vs Nurture We now know that neither of these extreme positions fully explain the complexity of the brain It is much more probable that psychiatric disorders result from some combination of the 2 theories

12. The Nurse-Client Relationship: An Art and a Science First described by Hildegard Peplau in her text Interpersonal Relations in Nursing (1952)

13. The Art The art of caring is the basis for PMHN and is embodied in the nurse-client relationship. The nurse-client relationship is often referred to as a therapeutic alliance which is used to effect change, promote growth, and heal mental and emotional wounds.

14. Core Characteristics of a Successful Therapist Empathy Warmth Genuineness Respect Concreteness Immediacy Confrontation Self-Disclosure

15. The Science

16. I. Principles of the Nurse-Client Relationship

17. Principles of the Nurse-Client Relationship The relationship is therapeutic rather than social The focus remains on the client�s issues rather than on the nurse�s or other issues The relationship is purposeful and goal directed It is objective versus subjective in quality It is time limited versus open ended

18. Therapeutic vs Social A therapeutic relationship is formed to help clients solve problems make decisions achieve growth learn coping strategies let go of unwanted behaviors reinforce self-worth examine relationships

19. Therapeutic vs Social The meetings between nurse and client are not for mutual satisfaction. The nurse can be friendly with the client, but is not there to be the client�s friend. The majority of the interaction is focused and therapeutic.

20. Client Focus During an interaction, a client may redirect the focus away from self by changing the subject, talking about the weather, etc. The nurse needs to recognize this as a divergent tactic, confront this behavior, and refocus the client.

21. Goal Direction The primary purpose of a therapeutic relationship is helping clients to meet adaptive goals. Nurse and client work together to identify problematic areas in client�s life Once goals are established, the nurse and client agree to work toward those goals.

22. Objective vs Subjective Nurses can be therapeutic only if they remain objective. Objectivity refers to remaining free from bias, prejudice, and personal identification in interaction with the client and being able to process information based on facts. Subjectivity refers to emphasis on one�s own feelings, attitudes, and opinions when interacting with the client.

23. Time-Limited Interactions Time of meetings Number of meetings that will take place Provides structure Lets client know that relationship will end

24. Stages of the Nurse-Client Relationship Preorientation phase Orientation phase Working phase Termination phase

25. Preorientation Phase Takes place prior to meeting with the client 1st gather data about the client, his or her condition, and the present situation Nurse then examines his or her thoughts, feelings, perceptions, and attitudes about this particular client

26. Orientation Phase The nurse-client become acquainted; build trust and rapport A contract is established Includes time and place for the meeting, as well as the purpose of the meetings Dependability is imperative for both the nurse and the client Client strengths, limitations, and problem areas are identified Outcome criteria and a plan of care are established

27. Working Phase Orientation phase ends and working phase begins when the client takes responsibility for his or her own behavior change Client shows commitment to working on issues that have caused a life disruption Clients� needs are prioritized- safety and health come first RN assists the client to change problematic behaviors in a safe environment

28. Termination Phase Relationship comes to a close This phase begins in the orientation phase when meeting times are established- lets the client know that the relationship will come to an end Avoids confusing the client who may be unable to recognized boundaries in a relationship Termination occurs when the client has improved or has been discharged

29. II. Nursing Scope of Practice

30. Nursing Scope of Practice Standards of care and practice for psychiatric mental health nurses were developed by the American Nurses Association and continue to describe functions.

31. Basic Practice Level At the basic practice level, nurses can intervene in the following ways: Counseling described by the ANA as including interviewing and communication techniques, problem solving, crisis intervention, stress management, and behavior modifications

32. Basic Practice Level (cont.) Milieu Therapy The environment is used as a therapeutic tool to modify behaviors, teach skills, and encourage communication between the client and others. Self-Care Activities Encouraging independence within a client�s ability and capacity urges clients to take responsibility for their care thus improving their self esteem.

33. Basic Practice Level (cont.) Psychobiologic Interventions �Knowledge of medications used in the psychiatric setting Health Teaching Health Promotion and Health Maintenance Case Management �Coordinates comprehensive health services and ensures continuity of care

34. Advanced Practice Level The following interventions may be employed by clinical specialists and nurse practitioners who are certified in advanced psychiatric mental health nursing: Psychotherapy Prescription of Pharmacologic Agents Consultation Education

35. III. Mental Health and Mental Disorder

36. Defining and Classifying Mental Health and Mental Disorder The ANA defines mental health as a state of well-being in which individuals function well in society and are generally satisfied with their lives. Results in socially acceptable behavior and the ability to respond productively and appropriately in the environment

37. Defining and Classifying Mental Health and Mental Disorder Mental disorder is a disturbance in an individual�s thinking, emotions, behaviors, and physiology. Leads to problems with behavior, relationships, and functioning.

38. Mental Illness and Mental Health Continuum Mild?joys, sorrows, and anxiety levels that aid in the work of living Mild-Moderate?psychophysiologic factors affecting medical conditions Moderate-Severe?anxiety d/os, dissociative d/os, somatoform d/os, personality d/os, and eating d/os Severe-Psychosis?depressive d/os, bipolar d/os, schizophrenic d/os, and cognitive d/os

39. IV. Psychiatric Diagnoses

40. Psychiatric Diagnoses Precise descriptions and classifications of mental disorders Represents a specific set of sx or syndrome Allows for easier communication among mental health care providers Permits Rx based on pt�s dx Prognosis

41. Diagnostic Nomenclatures A nomenclature of psychiatric diagnoses developed by the APA is widely accepted in the US as the official diagnostic criteria in clinical, research, and educational settings. The diagnoses are published in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. (DSM IV-TR)

42. DSM IV-TR A multiaxial classification scheme that allows for the interrelation of biological, psychological, and social aspects of an individual�s condition. Axis I � the psychiatric diagnosis Axis II � personality disorders and mental retardation Axis III � general medical conditions Axis IV � psychosocial and environmental problems Axis V � GAF- rates the overall psychological functioning of the client on a scale of 0-100.

43. NANDA Nomenclature of nursing diagnoses Many applicable in the psychiatric setting

44. V. The Nursing Process

45. The Nursing Process A scientific, problem-solving method that assists nurses in total client care. Consists of 6 steps Assessment Diagnosis Outcome Identification Planning Implementation Evaluation

46. VI. Therapeutic Treatment Modalities

47. Therapeutic Rx Modalities Traditional inpatient hospitalization has been replaced with an entire range of care options Rx options include: Inpatient hospitals Outpatient day treatment programs Clinics Home care Community centers Crisis centers Place of employment/school

48. Therapeutic Rx Modalities (cont.) Types of Therapies Interactive therapies- includes all of those in which the client has interpersonal contact with 1 or more therapists and includes interaction with other clients Biologic therapies- includes the use of medications and ECT

49. VII. Current Epidemiology and Research

50. Current Epidemiology and Research Approx 28% of Americans over the age of 18 suffer from a mental or addictive disorder in a 1 year period See page 11 in the text for prevalence of psych d/os in the US

51. VIII. Prevention of Disorders

52. Prevention of Disorders Gerald Caplan (1964) proposed a model for preventive care of persons with mental disorders. Model proposes 3 levels of preventions Primary Secondary Tertiary

53. Primary Prevention Focuses on reduction of the incidence of mental disorders within the community Emphasizes health promotion and prevention Example: Teaching stress reduction techniques to any population

54. Secondary Prevention Directed toward reducing the prevalence of mental disorders through early identification and early Rx of those problems Example: assessing sx of depression such as sleep disturbances, appetite changes, diminished interest during routine interview with client; if problem identified- treat

55. Tertiary Prevention Has the dual focus of reducing residual effects of the disorder and rehabilitating the individual who experienced the mental disorder Example: Social skills training to a schizophrenic

56. IX. Roles of the Mental Health Team

57. Roles of the Mental Health Team Psychiatric Nurse Has the most widely focused position description of any of the member roles Interacts with clients in individual and group settings Manages client care Administers and monitors meds Teaches both clients and families Acts as a client advocate

58. Roles of the Mental Health Team Psychiatric Social Worker Graduate level position Work with clients on an individual basis Conduct group therapy sessions Act as liaisons with the community to place clients after discharge

59. Roles of the Mental Health Team Psychiatrist Licensed medical physician who specializes in psychiatry Prescribe and monitor meds Admit clients into acute care settings Administer ECT Conduct individual and family therapy

60. Roles of the Mental Health Team Psychologist Licensed individual with a doctoral degree in psychology Assess and treat psychologic and psychosocial problems of individuals, families, or groups Do not prescribe or administer medications Administer psychometric tests that aid in the diagnosis of disorders

61. Roles of the Mental Health Team Marriage, Family, Child Counselor Licensed individuals who frequently work in private practice Prepared to work with individuals, couples, families, and groups Emphasize the interpersonal aspects of achieving and maintaining relationships

62. Roles of the Mental Health Team Case managers Facilitate the delivery individualized, coordinated care in cost-effective ways Need to know the various types of hospitalization and outpatient care settings, the coverage offered by different payers, and the impact of state and federal legislation

63. X. Trends and Issues of the Future

64. Trends and Issues of the Future Dominant issue in mental health is managed care The outcome of managed care for clients and families with mental disorders are reported to be ineffective Because of managed care and lack of funding, clients are often discharged before they are ready to leave the hospital