Mental health nursing

Psychiatric nursing or mental health nursing is the specialty of nursing that cares for people of all ages with mental illness or mental distress, such as schizophrenia, bipolar disorder, psychosis, depression or dementia. Nurses in this area receive more training in psychological therapies, building a therapeutic alliance, dealing with challenging behavior, and the administration of psychiatric medication.

Therapeutic relationship

Main article: Therapeutic relationship

As with other areas of nursing practice, psychiatric mental health nursing works within nursing models, utilizing nursing care plans, and seeks to care for the whole person. However, the emphasis of mental health nursing is on the development of a therapeutic relationship or alliance. In practice, this means that the nurse should seek to engage with the person in care in a positive and collaborative way that will empower the patient to draw on his or her inner resources in addition to any other treatment they may be receiving.

History

The history of psychiatry and psychiatric nursing, although disjointed, can be traced back to ancient philosophical thinkers. Marcus Tullius Cicero, in particular, was the first known person to create a questionnaire for the mentally ill using biographical information to determine the best course of psychological treatment and care. Some of the first known psychiatric care centers were constructed in the Middle East during the 8th century. The medieval Muslim physicians and their attendants relied on clinical observations for diagnosis and treatment.

In 13th century medieval Europe, psychiatric hospitals were built to house the mentally ill, but there were not any nurses to care for them and treatment was rarely provided. These facilities functioned more as a housing unit for the insane. Throughout the highpoint of Christianity in Europe, hospitals for the mentally ill believed in using religious intervention. The insane were partnered with “soul friends” to help them reconnect with society. Their primary concern was befriending the melancholy and disturbed, forming intimate spiritual relationships. Today, these soul friends are seen as the first modern psychiatric nurses.

In the colonial era of the United States, some settlers adapted community health nursing practices. Individuals with mental defects that were deemed as dangerous were incarcerated or kept in cages, maintained and paid fully by community attendants. Wealthier colonists kept their insane relatives either in their attics or cellars and hired attendants, or nurses, to care for them. In other communities, the mentally ill were sold at auctions as slave labor. Others were forced to leave town. As the population in the colonies expanded, informal care for the community failed and small institutions were established. In 1752 the first “lunatics ward” was opened at the Pennsylvania Hospital which attempted to treat the mentally ill. Attendants used the most modern treatments of the time: purging, bleeding, blistering, and shock techniques. Overall, the attendants caring for the patients believed in treating the institutionalized with respect. They believed if the patients were treated as reasonable people, then they would act as such; if they gave them confidence, then patients would rarely abuse it.

The 1790s saw the beginnings of moral treatment being introduced for people with mental distress. The concept of a safe asylum, proposed by Phillipe Pinel and William Tuke, offered protection and care at institutions for patients who had been previously abused or enslaved. In the United States, Dorothea Dix was instrumental in opening 32 state asylums to provide quality care for the ill. Dix also was in charge of the Union Army Nurses during the American Civil War, caring for both Union and Confederate soldiers. Although it was a promising movement, attendants and nurses were often accused of abusing or neglecting the residents and isolating them from their families.

The formal recognition of psychiatry as a modern and legitimate profession occurred in 1808. In Europe, one of the major advocates for mental health nursing to help psychiatrists was Dr. William Ellis. He proposed giving the “keepers of the insane” better pay and training so more respectable, intelligent people would be attracted to the profession. In his 1836 publication of Treatise on Insanity, he openly stated that an established nursing practice calmed depressed patients and gave hope to the hopeless. However, psychiatric nursing was not formalized in the United States until 1882 when Linda Richards opened Boston City College. This was the first school specifically designed to train nurses in psychiatric care. The discrepancy between the founding of psychiatry and the recognition of trained nurses in the field is largely attributed to the attitudes in the 19th century which opposed training women to work in the medical field.

In 1913 Johns Hopkins University was the first college of nursing in the United States to offer psychiatric nursing as part of its general curriculum. The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey, was not published until 1920. It was not until 1950 when the National League for Nursing required all nursing schools to include a clinical experience in psychiatry to receive national accreditation. The first psychiatric nurses faced difficult working conditions. Overcrowding, under-staffing and poor resources required the continuance of custodial care. They were pressured by an increasing patient population that rose dramatically by the end of the 19th century. As a result, labor organizations formed to fight for better pay and fewer hours. Additionally, large asylums were founded to hold the large number of mentally ill, including the famous Kings Park Psychiatric Center in Long Island, New York. At its peak in the 1950s, the center housed more than 33,000 patients and required its own power plant. Nurses were often called “attendants” to imply a more humanitarian approach to care. During this time, attendants primarily kept the facilities clean and maintained ordered among the patients. They also carried out orders from the physicians.

In 1963, President John F. Kennedy accelerated the trend towards deinstitutionalization with the Community Mental Health Act. Also, since psychiatric drugs were becoming more available allowing patients to live on their own and the asylums were too expensive, institutions began shutting down. Nursing care thus became more intimate and holistic. Expanded roles were also developed in the 1960s allowing nurses to provide outpatient services such as counseling, psychotherapy, consultations, prescribing medications, along with the diagnosis and treatment of mental illnesses.

The first developed standard of care was created by the psychiatric division of the American Nurses Association (ANA) in 1973. This standard outlined the responsibilities and expected quality of care of nurses.

Assessment

The term mental health encompasses a great deal about a single person, including how we feel, how we behave, and how well we function. This single aspect of our person cannot be measured or easily reported but it is possible to obtain a global picture by collecting subjective and objective information to delve into a person’s true mental health and well being. When identifying mental health wellness and planning interventions, here are a few things to keep in mind when completing a thorough mental health assessment in the nursing profession:

• Is the patient sleeping adequate hours on a regular sleeping cycle?
• Does the patient have a lack of interest in communication with other people?
• Is the patient eating and maintaining an adequate nutritional status?
• Is the ability to perform activities of daily living present (bathing, dressing, toileting one self)?
• Can the patient contribute to society and maintain employment?
• Is the ability to reason present?
• Is safety a recurring issue?
• Does the patient often make decisions without regards to their own safety or the safety of others?
• Does the patient show a difficulty with memory or recognizance?

Interventions

Nursing interventions may be divided into the following categories:

Physical and biological interventions

Psychiatric medication

Psychiatric medication is a commonly used intervention and many psychiatric mental health nurses are involved in the administration of medicines, both in oral (e.g. tablet or liquid) form or by intramuscular injection. Nurses will monitor for side effects and response to these medical treatments by using assessments. Nurses will also offer information on medication so that, where possible, the person in care can make an informed choice, using the best evidence available.

Electroconvulsive therapy

Psychiatric mental health nurses are also involved in the administration of the treatment of electroconvulsive therapy and assist with the preparation and recovery from the treatment, which involves an anesthesia. This treatment is only used in a tiny proportion of cases and only after all other possible treatments have been exhausted. Approximately 85% of clients receiving ECT have major depression as the indication for use, with the remainder having another mental disease such as schizoaffective disorder, mania or schizophrenia.

Physical care

Along with other nurses, psychiatric mental health nurses will intervene in areas of physical need to ensure that people have good levels of personal hygiene, nutrition, sleep etc. as well as tending to any concomitant physical ailments.

Psychosocial interventions

Psychosocial interventions are increasingly delivered by nurses in mental health settings and include psychotherapy interventions such as cognitive behavioural therapy, family therapy and less commonly other interventions such as milieu therapy or psychodynamic approaches. These interventions can be applied to a broad range of problems including psychosis, depression, and anxiety. Nurses will work with people over a period of time and use psychological methods to teach the person psychological techniques that they can then use to aid recovery and help manage any future crisis in their mental health. In practice, these interventions will be used often, in conjunction with psychiatric medications. Psychosocial interventions are based on evidence based practice and therefore the techniques tend to follow set guidelines based upon what has been demonstrated to be effective by nursing research. There has been some criticism that evidence based practice is focused primarily on quantitative research and should reflect also a more qualitative research approach that seeks to understand the meaning of people's experience.

Spiritual interventions

The basis of this approach is to look at mental illness or distress from the perspective of a spiritual crisis. Spiritual interventions focus on developing a sense of meaning, purpose and hope for the person in their current life experience. Spiritual interventions involve listening to the person's story and facilitating the person to connect to God, a greater power or greater whole, perhaps by using meditation or prayer. This may be a religious or non-religious experience depending on the individual's own spirituality. Spiritual interventions, along with psychosocial interventions, emphasize the importance of engagement, however, spiritual interventions focus more on caring and 'being with' the person during their time of crisis, rather than intervening and trying and 'fix' the problem. Spiritual interventions tend to be based on qualitative research and share some similarities with the humanistic approach to psychotherapy.

Organization of mental health care

Psychiatric mental health nurses work in a variety of hospital and community settings.

People generally require an admission to hospital, voluntarily or involuntarily if they are experiencing a crisis- that means they are dangerous to themselves or others in some immediate way. However, people may gain admission for a concentrated period of therapy or for respite. Despite changes in mental health policy in many countries that have closed psychiatric hospitals, many nurses continue work in hospitals though patient length of stay has decreased significantly.

Community Nurses who specialize in mental health work with people in their own homes (case management) and will often emphasize work on mental health promotion. Psychiatric mental health nurses also work in rehabilitation settings where people are recovering from a crisis episode and the where the aim is social inclusion and a return to living independently in society. These nurses are sometimes referred to as community psychiatric nurses (the term psychiatric has been retained, but is being gradually replaced with the title "Community Mental Health Nurse" or CMHN)).

Psychiatric mental health nurses also work in forensic psychiatry with people who have mental health problems and have committed crimes. Forensic mental health nurses work in adult prisons, young offenders' institutions, medium secure hospitals and high secure hospitals. In addition forensic mental health nurses work with people in the community who have been released from prison or hospital and require on-going mental health service support.

People in the older age groups who are more prone to dementia tend to be cared for apart from younger adults. Admiral Nurses are specialist dementia nurses, working in the community, with families, carers and supporters of people with dementia. The Admiral Nurse model was established as a direct result of the experiences of family carers. The Admiral nurse role is to work with family carers as their prime focus, provide practical advice, emotional support, information and skills, deliver education and training in dementia care, provide consultancy to professionals working with people with dementia and promote best practice in person- centred dementia care.

Psychiatric mental health nurses may also specialize in areas such as drug and alcohol rehabilitation, or child and adolescent mental health.

UK, Ireland, US, and Canada

See also: Psychiatric and mental health nurse practitioner and Registered psychiatric nurse

Canada

The registered psychiatric nurse is a distinct nursing profession in all of the four western provinces. Such nurses carry the designation "RPN". In Eastern Canada, an Americanized system of psychiatric nursing is followed.

Ireland

In Ireland, mental health nurses undergo a 4 year honors degree training programme. Nurses that trained under the diploma course in Ireland can do a post graduation course to bring their status from diploma to degree.

UK

In the UK and Ireland the term psychiatric nurse has now largely been replaced with mental health nurse. Mental health nurses undergo a 3-4 year training programme at either diploma or degree level, in common with other nurses. However, most of their training is specific to caring for clients with mental health issues.

US

In North America, there are three levels of psychiatric nursing.

• The licensed vocational nurse (licensed practical nurse in some states) and the licensed psychiatric technician may dispense medication and assist with data collection regarding psychiatric and mental health clients.

• The registered nurse or registered psychiatric nurse has the additional scope of performing assessments and may provide other therapies such as counseling and milieu therapy.

• The advanced practice registered nurse (APRN) either practices as a clinical nurse specialist or a nurse practitioner after obtaining a Master’s degree in psychiatric-mental health nursing and. Psychiatric-mental health nursing (PMHN) is a nursing specialty. The course work in a Master’s degree program includes specialty practice. APRN’s assess, diagnose, and treat individuals or families with psychiatric problems/disorders or the potential for such disorders, as well as performing the functions associated with the basic level. They provide a full range of primary mental health care services to individuals, families, groups and communities, function as psychotherapists, educators, consultants, advanced case managers, and administrators. In many states, APRN’s have the authority to prescribe medications. Qualified to practice independently, psychiatric-mental health APRN’s offer direct care services in a variety of settings: mental health centers, community mental health programs, homes, offices, HMOs, etc.

Psychiatric nurses who earn doctoral degrees (PhD, DNSc, EdD) often are found in practice settings, teaching, doing research, or as administrators in hospitals, agencies or schools of nursing.

See also

• Psychiatric and mental health Nurse Practitioner
• Mental health professional
• List of counseling topics
• Hildegard Peplau - psychiatric nurse theorist
• Tidal Model - model developed for mental health nursing

References

12. Drury, V., Francis, K., & Dulhunty, G. (2005). The lived experience of rural mental health nurses. Online Journal of Rural Nursing and Healthcare, 5(1).