1. Chapter 1: Foundations of Psychiatric-Mental Health Nursing

2. No single, universal definition Many components influenced by factors
Mental Health
Difficult to define
No single, universal definition
Many components influenced by factors
Dynamic, ever-changing state
Influencing factors:
Individual (personal)
Interpersonal (relationship)
Social/cultural (environmental)

3. Mental Illness
Mental disorder: behavioral or psychological syndrome or pattern (clinically significant)
Association with present distress or disability or increased risk of death, pain, disability or important loss of freedom

4. Mental Illness (cont’d)
General criteria for diagnosis
Dissatisfaction with characteristics, abilities, accomplishments
Ineffective or unsatisfying relationships
Dissatisfaction with one’s place in the world
Ineffective coping with life events
Lack of personal growth

5. Diagnostic and Statistical Manual of Mental Disorders
DSM-IV-TR: taxonomy of American Psychiatric Association
Purposes:
Standardize nomenclature, language
Identify defining characteristics or symptoms
Assist in identifying underlying causes

6. DSM-IV-TR Classification
Axis I: major psychiatric disorders except mental retardation, personality disorders
Axis II: mental retardation, personality disorders
Axis III: current medical conditions potentially relevant
Axis IV: psychosocial, environmental problems
Axis V: Global Assessment of Functioning

7. Question
Tell whether the following statement is true or false:
The definition of mental health is standardized and universally accepted.

8. Answer
False
There is no single universal definition of mental health, which has many components and is influenced by myriad factors.

9. Historical Perspectives
Ancient times
Sickness as displeasure of gods; punishment for sins; view as demonic or divine
Aristotle and imbalances of the four humors (blood, water, yellow and black bile); balance restoration via bloodletting, starving, purging
Early Christians’ view as possession by demons

10. Historical Perspectives (cont’d)
Period of Enlightenment (1790s)
Creation of asylums; moral treatment
Dorothea Dix
Sigmund Freud: scientific study, treatment of mental illness

11. Historical Perspectives (cont’d)
Psychopharmacology (1950s): development of psychotropic drugs
Community mental health movement
Deinstitutionalization
Legislation for disability income
Changes in commitment laws

12. Mental Illness and the 21st Century
Current state
More than 26% of Americans 18 and older have diagnosable mental disorder (NIMH, 2008)
15 million adults, 4 million children and adolescents with impaired daily activities
Economic burden exceeds that by all types of cancer

13. Mental Illness and the 21st Century (cont’d)
Current state
Leading cause of disability in United States Canada for those years of age
1 in 4 adults and 1 in 5 children and adolescents getting care needed

14. Mental Illness and the 21st Century (cont’d)
Issues and concerns:
“Revolving-door” effect due to deinstitutionalization
Shorter hospital stays, decompensation, rehospitalization, dual diagnoses

15. Mental Illness and the 21st Century (cont’d)
Issues and concerns:
Homelessness (⅓ estimated to have serious mental illness; over ½ with substance abuse problems)
Lack of adequate community resources
ACCESS to address needs of full- or part- time homeless persons with mental illness

16. Question
Which statement best reflects the current state of mental health and mental illness?
Mental health care costs exceed the costs for cancer care.
Most adults and children receive adequate mental health care.
Community resources for the homeless with mental illness are adequate.
Deinstitutionalization has reduced the revolving door effect.

17. Mental health care costs exceed the costs for cancer care.
Answer
Mental health care costs exceed the costs for cancer care.
The economic burden of mental illness exceeds that for all types of cancer care.
Only 1 in 4 adults and 1 in 5 children received the necessary mental health care. Community resources for homeless clients with mental illness are inadequate. Deinstitutionalization has led to the “revolving-door” effect.

18. Objectives for the Future
Healthy People 2010 objectives
Increase number of people identified, diagnosed, treated, helped to live healthier lives
Decrease rates of suicide, homelessness
Increase employment for those with serious mental illness
Provide more services for incarcerated persons with mental health problems

19. Development of community support programs
Community-Based Care
Lack of appropriate number of community mental health centers to provide services
Development of community support programs
Availability, quality of services highly variable
Inaccurate anticipation of extent of people’s needs
Despite flaws, positive aspects making them preferable for treatment

20. Cost Containment and Managed Care
Managed care movement (early 1970s)
Development of utilization review firms/managed care organizations (1990s); case management
Separation of mental health care from physical care for insurance coverage

21. Cost Containment and Managed Care (cont’d)
Mental health care management through privately owned behavioral health care firms
If no private insurance, reliance on counties of residence for payment
HCFA: Medicare, Medicaid
Mental health parity, insurance coverage

22. Cultural Considerations
Culturally diverse population
Cultural differences influencing mental health, treatment of mental illness
Changes in family structure

23. Question
Tell whether the following statement is true or false:
Community-based programs are preferable for treating many people with mental illness.

24. Answer
True
Although there are flaws in the system, community-based programs have positive aspects that make them preferable for treating many people with mental illness.

25. Psychiatric Nursing Practice
Linda Richards: first American psychiatric nurse
McLean Hospital, Belmont MA: site of first training for nurses to work with persons with mental illness
Expansion of role with development of somatic therapies

26. Psychiatric Nursing Practice (cont’d)
First psychiatric nursing textbook (Nursing Mental Diseases) published in 1920
Johns Hopkins: first school of nursing to include psychiatric nursing course (1913)
National League for Nursing (1950) requiring schools to include psychiatric nursing experience

27. Psychiatric Nursing Practice (cont’d)
H. Peplau: therapeutic nurse-client relationship; interpersonal dimension (foundation for current practice)
J. Mellow: focus on client’s psychosocial needs, strengths
American Nurses Association and Standards of Care (see Box 1.3)
Psychiatric-Mental Health Nursing Phenomena of Concern (see Box 1.2)

28. Psychiatric Nursing Practice (cont’d)
Basic-level functions
Counseling
Milieu therapy
Self-care activities
Psychobiologic interventions
Health teaching
Case management
Health promotion, maintenance
Advanced-level functions
Psychotherapy
Prescriptive authority for drugs
Consultation, liaison
Evaluation

29. Student Concerns and Psychiatric-Mental Health Clinical Experience
Saying the wrong thing
Knowing what to do
Being rejected or not talking to student
Asking personal questions
Handling bizarre, inappropriate, or sexually aggressive behavior
Handling feeling unsafe

30. Student Concerns and Psychiatric-Mental Health Clinical Experience
Seeing someone known on the unit
Dealing with similar problems or backgrounds

31. Question
Tell whether the following statement is true or false:
The National League for Nursing required schools to include a psychiatric nursing experience before the first nursing school included a psychiatric nursing course in its curriculum.

32. Answer
False
Johns Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum; this was done in It was not until 1950 that the National League for Nursing required schools to include an experience in psychiatric nursing.

33. Self-Awareness Issues
Everyone with unique or different values, ideas, beliefs
Possible conflict between personal values/beliefs, those of client
Need to accept differences, view each client as worthwhile regardless of opinions or lifestyle
Self-awareness through reflection