Introduction to Psychiatric / Mental Health Nursing Philosophy and Theories for Interdisciplinary Psychiatric Care Chapter 1, 2 & 5 West Coast University NURSING 204

Caring for Psychiatric Mental Health Clients Feelings, Concerns, Questions—What Are They? Who Are They?

People with Mental Illness

Factors Influencing Expectations Media Other? Upbringing Expectations Life experiences Culture

Psychiatric Mental Health Clients Psychiatric mental health clients are everyday, ordinary people. Removing the stigma of Mental Illness Definition of Stigma: a mark of disgrace or infamy; a stain or reproach, as on one’s reputation Best defined as ignorance, prejudice and discrimination

Factors Impacting Mental Health and Mental Illness Biological Mental Illness or Mental Health Social Cultural

What do these terms mean? Crazy? Berserk? Wacky? Insane? Weird? Lunatic ? Nervous Breakdown? Melancholy?

Historical Approaches Era 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 Cullen Philippe Pinel William Tuke Benjamin Franklin Benjamin Rush “Father of American Psychiatry”

A ward in Bethlehem Hospital about 1745 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 dimensions Brain dysfunction Neurochemical Medication therapy 19th century and early 20th century.

21st Century Research Bases for mental disorders Psychotropic medications Role of nutrients, biology, and genetics

Mental Disorder Statistics High 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 Studies Epidemiologic Catchment Area (ECA) Global Burden of Disease (WHO) U.S. Surgeon General’s Report Healthy People 2020

Healthy People 2020 Reduce 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

Standards Standards of Psychiatric-Mental Health Nursing Practice: Guidelines for providing quality care Psychiatric-Mental Health Nursing Standards of Practice Assessment Diagnosis Outcomes Identification Planning

Standards - continued Psychiatric-Mental Health Nursing Standards of Practice Implementation Coordination of Care Health Teaching and Health Promotion Milieu Therapy Phamacological, Biological, and Integrative Therapies Prescriptive Authority and Treatment (APRN only) Psychotherapy (APRN only) Consultation (APRN only) Evaluation

Standards - continued Standards of Professional Performance Quality of Practice Education Professional Practice Evaluation Collegiality Collaboration Ethics Research Resource Utilization Leadership

Psychiatric-Mental Health Nurses Generalist level Advanced practice level Prescriptive authority Psychotherapy Consultation

Estimated Number of Mental Health Workers in the United States

The Mental Health Team

Effective Mental Health Services Client Partnerships 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 Custodial Multifaceted

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 - Value Nursing 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 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 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) Interactionism Individuals have purpose and control. Humanistic cast Interaction of psychology, psychobiology, and sociocultural contexts Humanism Devotion to individual interests Spirit of compassion and caring Affirming of the joy, beauty, and value of living

Nursing Implications Humanistic Interactionism Interrelated physical and mental factors Holistic Expanded role for psychiatric-mental health nurses Client and family role includes negotiation and advocacy.

Nursing Implication Psychobiology Focus on biological, medical, and human aspects of care. Holistic Integrative New knowledge “High tech” and “high touch” Nature and nurture Biologic 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 Theory Sigmund 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