Current Theories and Practice

Foundations of Psychiatric–Mental Health

Nursing

Learning Outcomes

• Define the characteristics of mental health and mental illness.

• Discuss the purpose and use of the DSM-IV-TR.• Identify important historical landmarks in

psychiatric care.• Discuss the ANA standards of practice for

psychiatric-mental health nursing.• Describe common student concerns about

psychiatric nursing.

Mental Health

• WHO definition: state of complete physical, mental, and social wellness, not merely absence of disease or infirmity

• Emotional, psychological, and social wellness evidenced by:

– Satisfying interpersonal relationships

– Effective behavior and coping as culture states

– A positive self-concept (self-esteem)

– Emotional stability

Factors Influencing a Person’s Mental Health

• Individual factors– Person traits, Bio Makeup, self-esteem, capacity for growth,

sense of belonging, now you can manage life.

• Interpersonal factors– Relationship traits, communication effectiveness, are you able

to handle intimacy, to act as an individual

• Social/cultural factors– Environmental factors- do you know what’s going on outside

of yourself and your tolerance of it; what’s going on around you; can you go to the store, job, school

– Have a realistic view of the world (war, healthcare, news, etc.)– Understand what’s going on w/ others around you.

Mental Illnessa life long struggle

• Historically- thought to be demon possessed or was being “punished” by a higher power.

• Today- Better understanding that it is a disease. Usually due to chemical imbalances.

Mental Illness (cont’d)

• Mental disorder is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (APA)

• Can they distinguish reality from fantasy• Can they communicate• Are they withdrawn• Are they homeless/poverty/lack resources• Can they have relationships

• The DSM-IV-TR® is published by APA and used by mental health professionals to describe all mental disorders according to specific diagnostic criteria– Classifies by axis

• The DSM-IV-TR is a multiaxial classification system

Manual of Mental Disorders

Axis I: Major psychiatric disorders except mental retardation and personality disorders The reason they were brought to the unit: depression, bipolar,

schizophrenia, major depressive disorder recurrent (The reason they’re there)

Axis II: Mental retardation, personality disorders Personality disorders, may or may not have

Axis III: Medical conditions DM, CHF, UTI, FM, meds are affected

Axis IV: Psychosocial and environmental problems Stressors of life: homeless, jobless, divorced, legal problems

Axis V: Global Assessment of Functioning (GAF) score GAF- measures disorder severity; Scale is 0-100 (<30 is

severe) a person can have 2 GAF scores

Where they are at right now 2nd is avg from previous times

Done on assessment, during treatment, on D/C Helps find appropriate care, meds, social work, class, TX

DSM-IV-TR (cont’d) pg 154Look at pts holistically

DSM-IV-TR (cont’d) pg 154Look at pts holistically

#1

[]=‘’’|’’’|’’’|>----

Four is “the box”

5 = GAF

2

Historical Perspective

• Period of Enlightenment– Start of asylums (safe place for “ill” pts)

• Period of Scientific Study– Psycho analysis, talk about feelings, info, education, to study

Mental Illness• Period of Psychotropic Drugs

– Drugs came out to treat (Lithium, Thorazine, etc.)• Thorazine- antipsychotic effects

• Period of Community Mental Health (1963)– Deinstitutionalization- based on Community Mental Health

Act- Pt allowed benefits & released back to Community.• Period of the Brain

– Focus care on pt needs, what pt wanted and not what we “think” they want.

Mental Illness in the 21st Century

• Over 26% of Americans age 18 and older have a diagnosable mental disorder: approximately 57.7 million persons diagnosed each year (NIMH, 2006)

• Hospital stays shorter, more numerous: revolving door D/C too soon

400% increase in ER visits

• Increased aggression among mentally ill clients

• More people with mental illness are incarcerated– 15% or more prisoners have Mental Illness

Mental Illness in the 21st Century (cont’d)

• Homeless population of persons with mental illness is growing (1/3 of homeless have Mental Illness)

• Most healthcare dollars still spent on inpatient psychiatric care; community services not adequately funded

• Healthy People 2010 Mental Health Objectives

(p.8 Box.1.1)

Mental Illness in the 21st Century (cont’d)

• Community-based care– Support service, housing, Case management. (anything outside of

the hospital) Tx usually occurs out in the community.

• Cost containment – Managed care, provider’s services. Most $ goes to Acute care,

General care, Tx, days in, No insurance (Mental health not considered illness).

• Cultural considerations– Because of diversity giving care has become more challenging

– Different beliefs (ex: about why they are ill)

Psychiatric Nursing Practice determines what is safe & acceptable

• Standards of Psychiatric-Mental Health

Clinical Nursing Practice: this outlines areas of concern and standards of care for mental health nurse (p.11-12)

• Psychiatric Mental Health Nursing

Phenomena of Concern: 12 areas of concern that mental health nurses focus on when caring for patients (p.10)

No test Q’s

Student Concerns

• Saying the wrong thing• What student will be doing• Fear of no one talking to student• Bizarre or inappropriate behavior• Physical safety• Seeing someone known to the

student

Self-Awareness Issues

- Everyone has values, beliefs, ideas; nurses need to know what theirs are, not to change them, but to prevent unknown or undue influence on their nursing practice

- Hints to increase self-awareness: keep a journal, talk to trusted coworkers, examine points of other than one’s own view

Treatment Settings and Therapeutic Programs

Learning Outcomes

• Describe different types of treatment settings and the services they provide.

• Identify barriers to effective treatment for special populations with mental illness.

• Describe the roles of different members of the multidisciplinary mental health care team

• Identify the nurse’s roles in treatment settings

Mental Health Settings

• Inpatient setting-acute inpatient hospitals, where stabilize patient and dismiss patient back to community

• Community setting-mental health care conducted in clinics, rehabilitation programs, crisis centers, ACT,etc.

Inpatient Hospital Treatment

In the 1990’s, managed care shortened hospital stays; people were sicker when admitted and were discharged sooner, rendering milieu therapy and “talk” therapy ineffective

Inpatient Hospital Treatment

• Rapid assessment, stabilization, and discharge planning

• Patient-centered focus on keeping pt safe and stable, involve pt in pt care

• Multidisciplinary- Social workers, Psychiatric nurse, Psychiatric social worker, Occupational therapist, Recreational therapist, Psychiatrist

Inpatient Hospital Treatment Includes

• Scheduled inpatient stays- (Med changes or diff treatment) not doing well, just coming in trying to fix problem

• Long-stay patients- Come in for legal reasons, make sure they can stand trial. Mandated by law. (30-90 days for evaluation)

• Case management- starts from the time that they are admitted to D/C. Does the pt have any transportation needs. Check what kind of services are the clients eligible for.

• Discharge planning- the better the D/C planning the longer the pt will thrive in society.

Case Management

• Liaison between the patient and community resources, home care, and third party payers

• Access needed medical and psychiatric services, including help in carrying out tasks of daily living such as using public transportation, managing money, and buying groceries

pg68

Discharge Planning

• Effective discharge planning is crucial b/c of prolapse (ask: Do they have a place/home to go to?)

• Barriers to effective discharge planning include:

– Alcohol and drug abuse

– Criminal or violent behavior

– Noncompliance with medications

• Suicidal ideation

Discharge Planning (cont’d)

Keys to successful discharge planning:

• Staff communication• Patient outpatient program visits• Family involvement (present or not)

– important for successful outcome

• Services geared toward survival in the community and rehabilitation compliance

• Housing and transportation for patient– #1 important key to D/C planning

Partial Hospitalization ProgramsCome to the unit during the day and go home at night.

2-3wks ~duration

Transition to independent community living by:

– Focusing on stabilizing psychiatric symptoms

– Monitoring drug effectiveness

– Stabilizing living environment

– Improving activities of daily living

– Learning to structure time

– Obtaining meaningful work

– Providing follow-up for health concerns

pg69

Residential SettingsLong term, keep in mind limited $$$

• Vary according to the level of supervision, structure, and services provided, as well as the intent of the services

• Types of residential services include:

– Board and care homes- pt come and go

– Adult foster homes- family takes them in; making sure they get to school and have meals

– Halfway houses- places where offenders work and pay rent while undergoing counseling

– Supervised apartment living- minor/no monitoring

– Group homes- helps multiple people function as a unit.

Rehabilitation Treatment Programs

• Emphasize on recovery (30day or more to Tx)

• Reintegration into the community

• Empowerment, increased independence

• Gained an improved quality of life

• Recovery- still have illness, but is sxm free

• Cure- absence of illness altogether

• Rehab Tx- ex: for ETHOL, substance abuse

Assertive Community Treatment• ACT- community based treatment

– offering outreach services: (24/7 MHMR)

• Med Monitoring

• Make Dr’s appointments

• ACT programs involve:

– A problem-solving orientation; no problem is too small

– Direct provision of service rather than referral

– One prob is not having enough staff for everyone

Assertive Community Treatment (cont’d)

• Intensity (3 or more face-to-face contacts per week)

• A team approach rather than having one assigned case manager

• A long-term commitment for as long as the patient needs services

Special Populations

• Homeless

– When compared with homeless persons who are not mentally ill, the homeless mentally ill:

• Spend more time in jail

• Are homeless longer

• Spend more time in shelters

• Have less family contact

• Face greater barriers to employment

Special Populations (cont’d)

• Prisoners

– Up to 15% of persons in jail or prison have severe mental illness

• Criminalization of mental illness refers to prosecuting mentally ill offenders, even for misdemeanors, at a rate four times that of the general population in an effort to contain them in some type of institution

Special Populations (cont’d)

• Criminalization of mental illness is fueled by:

– Increasing public concern that mentally ill persons are violent (though higher chance of person hurting themselves)

– More stringent “harsh” commitment laws

– Lack of community support

– Deinstitutionalization

Interdisciplinary Team

• A multidisciplinary or interdisciplinary team involves the collaboration of a variety of disciplines to provide the most comprehensive, effective services for patients

pg74

Interdisciplinary Team (cont’d)

• Each member makes a unique contribution

– Psychiatric nurse

– Psychiatric social worker

– Occupational therapist

– Recreational therapist

– Psychiatrist

Self-Awareness Issues

• Evolution of care away from inpatient settings into community

• Nontraditional settings such as jails or homeless shelters

• Empowering patients to make their own decisions

• Frustration of working with patients who have persistent and severe mental illness

pg75