Mental Health

Nursing 304 Frameworks and Basic Concepts for Providing Nursing Care to Clients and Families Experiencing Psychiatric Disorders

Mental Health 

--”is defined as successful performance of mental functions, resulting in the ability to engage in productive activities, enjoy fulfilling relationships, and change or cope with adversity” (p. 2)

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Mentally Healthy 

A person is mentally healthy when a person possesses knowledge of oneself; meets one’s basic needs; assumes responsibility for one’s behavior and for self-growth; has learned to integrate thoughts, feelings, and actions; and can resolve conflicts successfully.

A mentally healthy person maintains relationships, communicates directly with others, and respects others.  A mentally healthy person adapts to change in one’s environment. 

Mental Illness 

-- “is considered a clinically significant behavioral or psychological syndrome experienced by a person and marked by distress, disability, or the risk of suffering disability or loss of freedom” (p. 2)

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Mentally Ill The mentally ill show deficits in functioning; it is usually these deficits that bring them to the facilities where you will encounter them.  Mental illness occurs when an individual is not able to view oneself clearly or has a distorted view of self, is unable to maintain satisfying personal relationships, and is unable to adapt to one’s environment. 

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The American Psychiatric Association defines mental disorder as “clinically significant behavior or psychological syndrome or pattern that occurs in an individual and is associated with present distress (i.e., negative response to stimuli that are perceived as threatening) or disability (i.e., impairment increased risk of suffering, death, pain, disability, or an important loss of freedom).

Mental Health Versus Mental Illness Signs of Mental Health Mental

Signs of Illness

(See Table 1-1, p. 5)

Prevalence of Psychiatric Disorders in the United States (See Table 1-2, p. 7)

Chapter 2: Psychiatric Nursing Evolution of a Specialty 

Care of the Mentally Ill 

Early Civilization The insane were treated through magical rituals, prayer, and exorcism.  The Greek and Roman cultures developed ideas of body “humors” – blood, black bile, yellow bile, and phlegm-which could influence emotional stability.  Hippocrates believed that excesses of black bile caused melancholy and that bloodletting could remove this excess. 

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Middle Ages and Renaissance The term “lunatic” emerged to refer to one controlled by the lunar body.  Treatment of the mentally ill was influenced by beliefs that the mentally ill were evil, witches, or heretics.  The mentally ill were excluded from community life or institutionalized.  Care was custodial and were poorly fed and clothed and were restrained. 

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Eighteenth and Early Nineteenth Centuries The mentally ill were committed to asylums.  They were place in prison if they committed a crime.  Their care was performed by persons without training or interest in helping others and was often lacking in compassion.  A few physicians in the U.S. and England began to view the insane as persons suffering disease and needing some kind of treatment. 

English physician William Battie’s word elevated mental services to something respectable physicians could do. He also believed that the care of the mentally ill should be done by carefully selected and trained.  Insanity was viewed as a disease.  Physicians began to classify mental disorders.  They described moral and physical causes of mental illness.  In 1846, the term psychiatry was introduced by physicians and they published their work in The Journal of Mental Science. 

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Asylums were built for the treatment and cure of the insane.

-Nineteenth Century  Conditions in the asylums became unbearable.  There was a called for reform.  Dorothea Lynde Dix became a leader for reform. She advocated for humane treatment as well as safe and comfortable environments for the patient. Through her efforts, care was improved in the U.S., Canada, and Scotland.

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Nursing Education 

Eighteenth and Nineteenth Centuries In 1882, the McLean Asylum in Somerville, Massachusetts, opened the first training school in the world for mental health nurses.  Edward Cowles, the physician superintendent of McLean, believed that the presence of a “nurse” indicated not only that the patient was ill but also that there was a hope of recovery. 

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Other schools were opened: Bellevue Training School in New York  Connecticut Training School in New Haven These schools operated under the Nightingale model. 

The year 1893 marked the first meeting of organized nursing in the U. S. Important Nurse Leaders included: Isabel Hampton and Lavinia Dock. Mental health nurses continued to be trained at asylums and their training evolved to keep up with new approaches in psychiatric care.

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Twentieth Century The American Psychiatric Association established a committee on Training Schools for Nurses.  Johns Hopkins Hospital School included psychiatric nursing in the training of general nurses. This was the first time a hospital program offered training in psychiatric care to all students.  By 1920, the first psychiatric nursing textbook was publish, Nursing Mental Disease by Harriet Bailey.  In the 1930s, somatic therapies emerged 

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In 1946, the U.S. Congress passed the National Mental Health Act, which established the National Institutes of Mental Health.

Peplau and the Therapeutic Relationship 

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Peplau was the first nurse to identify psychiatric nursing both as a essential element of general nursing and as a specialty area that embraces specific governing principles” (p. 24). She was the first nurse to describe the nurse-patient relationship as foundation of nursing practice (p. 24).

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She emphasizes the shifting the focus from what nurses do to patients to what nurses do with patients. She described that stages of the nurse-patient relationship (p. 24). The skills of the psychiatric nurse include: observation, interpretation, and intervention.

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She also applied Sullivan’s theory of anxiety to nursing practice.

Dorothea Orem 

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Proposed a general self-care deficit theory of nursing. Has three constitute theories –selfcare, self-care deficit, and nursing systems which are based on six central and one peripheral concept.

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Self-care Self-care agency Therapeutic self-care demand Self-care deficit Nursing agency Nursing system

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Focus: Goal of self-care as integral to the practice of nursing (p. 25) She emphasized the role of the nurse in promoting self-care activities of the client; this has relevance to the seriously and persistently mentally ill client (p. 25).

Jean Watson 

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She first differentiated between nursing and medicine by stating that curing is the domain of medicine, and caring is the domain of nursing. She proposed 10 carative factors that involved forming a humanistic, altruistic system of values: instilling faith-hope; cultivating sensitivity to one’s self and

To others; developing helping-trust relationships; expressing positive and negative feelings’ using scientific problem-solving methods for decision making; promoting interpersonal teaching-learning; providing an environment that supports, protects, and corrects mental, physical, sociocultural, and spiritual aspects;

Assisting with the gratification of human needs; and allowing for existential-phenomenological forces. Source: Frisch, N. C., & Frisch, L. E. (2006). Psychiatric mental health nursing, 3rd ed. Australia: Thomson Delmar Learning. (p. 30)

Neuroscience as a Basis for Practice 

Mental phenomena are somehow caused by an array of biochemical and neurophysiological processes that take place from moment to moment.

Psychotropic Drugs 

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Pharmacological treatment of mental disturbances is directed at the suspected transmitter receptor problem. Transmitters (p. 40) Dopamine  Norepinephrine  Serotonin  Histamine  GABA 

Glutamate  Acetylcholine  Substance P  Somatostatin  Neurotensin 

What is psychiatric Mental Health Nursing? (p. 64) 

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Psychiatric nursing is “the diagnosis and treatment of human responses to actual or potential mental health problems” (p. 64) Box 4-1: Psychiatric Mental Health Nursing’s Phenomena of Concern (p. 64)

What do psychiatric Nurses Do? (p. 65)

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“to promote and maintain optimal mental functioning, to prevent mental illness (or further dysfunction), and to help clients regain or improve their coping abilities” (p. 65)

Psychiatric Mental Health Nursing Interventions (p. 66)

Basic Level Nursing  Counseling  Milieu therapy  Promotion of self-care activities  Psychobiological interventions  Health teaching  Case management  Health promotion and health maintenance

Advanced Level Nursing  All of the above plus Psychotherapy  Medication prescription and treatment  Consultation 

Where do psychiatric nurses work? (p. 87)   

Primary Prevention Secondary Prevention Tertiary Prevention

Cultural and Ethnic Considerations 

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Cultural is a complex whole, including knowledge, belief, art, moral, law, custom, and any other capabilities and habits acquired by man as a member of society. It comprises every verbal or behavioral system that transmits meaning. It is learned, shared, and everchanging.

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It is learned through socialization, shared by all group members, and associated with adaptation to the environment.

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Cultural blindness is the attempt to treat all person fairly by ignoring differences and acting as though the differences do not exist. Can be perceived as insensitivity just as readily as are stereotyping and ethnocentrism.

Normal vs. Abnormal Behavior 

What is normal in one culture may not be normal in another.

A Global Perspective 

Terms Minority (p. 100)  Culture (p. 100)  Ethnicity (p. 100)  Worldview (p. 100; Table 7-2 on p. 102)  Enculturation (p. 103) 

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Understanding Culture in the Context of Mental Illness

Table 7-3: Selected Nonverbal Communication Patterns (p. 103) “Deviance from cultural expectations is considered by others within the culture to be a problem and frequently is defined by the cultural group as “illness” (p. 103)

Legal and Ethical Guidelines 

Terms (p. 116) Ethics  Bioethics 

Five Principles of Bioethics     

Beneficence Autonomy Justice Fidelity (nonmaleficence) Veraceity

Guidelines 

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Box 8-1: Code of Ethics for Nurses (p. 117) Civil Rights Specific Client Rights Client Consent  Communication  Freedom from Harm  Dignity and Respect 

Confidentiality  Participation in Plan of Care 

Nursing Process       

Assessment (pp. 139 – 144) Diagnosis (p. 145) Outcomes (p. 146) Planning (pp. 146 – 148) Implementation (p. 148 – 149) Evaluation (p. 149) Documentation (p. 150)

Goals of a Therapeutic Relationship (p. 156)    

Facilitating communication Assisting Helping Promoting

Factors that Enhance Growth in Others (pp. 157 – 158)

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Genuineness Empathy Positive Regard

Establishing Boundaries 

Problem Areas Overhelping  Controlling  Narcissism 

Peplau’s Phases of NurseClient Relationship (pp. 163 – 168)

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Orientation Phase Working Phase Termination Phase

Tools of Psychiatric Mental Health Nursing 

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Communication is the key to successful psychiatric – mental healthy nursing. Psychiatric mental health nurses use tools of self and tools of knowledge in their work.

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Therapeutic communication is the purposeful use of dialog to bring about the client’s insight, control of symptoms, and/or healing. To accomplish therapeutic communication, the nurse needs to understanding communication theory and how to build a positive nurseclient relationship.

Physical Space 

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Denotes a sense of relationship between two people. Has meaning in communication. Public space = approximately 12 feet Social space = 9 to 12 feet Personal space = 18 inches to about 4 feet Intimate space = closer than 18 inches

Actions or Kinetics 

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Refer to movements, expressions, question, and posture that accompany interactions and influence communications. NOTE: They are almost always culture-bound.

Paralinguistic Cues 

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Provide the context in which the words are delivered, and they influence meaning directly. Include tone, pitch, emotions expressed verbally (such as anxiety or anger or fear), sounds of hesitation, nervous laughter, and nervous coughing. Must be interpreted within the context of the client’s cultural and

Touch 

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Is a form of communication used almost daily by nurses providing direct physical care and support to clients. Can convey warmth, positive regard, support during silence, and reassurance that the nurse if fully present and caring. Has many meanings (appropriate and inappropriate touching).

Verbal Communication 

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Is the use of words, written and spoken, to send messages to another. For communication to be most therapeutic, it must convey a respectful attitude, one that supports the individuality and self-esteem of both the client and the nurse.

Nonverbal Communication 

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Refers to all of the messages sent by others than verbal or written. Includes behaviors, cues, and presence (such as proximity) that sends a message.

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Techniques that Enhance Communication (p. 187188)

Using Silence Accepting Giving Recognition Offering Self Offering General Leads Giving Broad Openings Placing the Events in Time or Sequence

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Making Observations Encouraging Description of Perception Encouraging Comparison Restating Reflecting Focusing Exploring

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Giving Information Seeking Clarification Presenting Reality Voicing Doubt Seeking Consensual Validation Verbalizing the Implied Encouraging Evaluation

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Attempting to Translate into Feelings Suggesting Collaboration Summarizing Encouraging Formulation of a Plan of Action

Obstructive Communication    

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(pp. 191 – 192)

Giving Premature Advice Minimizing Feelings Falsely Reassuring Showing Nonverbal Signs of Boredom or Resentment Making Value Judgments Asking “why” question 63

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Asking Excessive Questions Giving Approval, Agreeing Disapproving, Disagreeing Changing the Subject

Levels of Psychiatric Mental Health Clinical Nursing Practice (p. 65)

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Basic Level Advanced Level 

Advanced practice RN – psychiatric mental health (APRN-PMH)

Levels of Anxiety    

Mild Anxiety (p. 213) Moderate Anxiety (p. 213) Severe Anxiety (p. 214) Panic Level of Anxiety (p. 215)

Two Common Features of Defense Mechanisms 

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“They all (except suppression) operate on an unconscious level, so that we are not aware of their operations” (p. 17). “They deny, falsify, or distort reality to make it less threatening” (p. 17).

Common Defense Mechanisms 

Most Healthy Defenses (pp. 217-218) Altruism  Sublimation  Humor  Suppression 

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Intermediate Defenses (p. 218) Repression  Displacement  Reaction Formation  Somatization 

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Immature Defenses (pp. 218-220) Passive aggression  Acting-Out Behaviors  Dissociation  Devaluation  Idealization Splitting  Projection  Denial 

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Regression Suppression Sublimation

(p. 95)