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Chapter 2
Psychiatric–Mental Health Nurses:
Who Are They?
Learning Outcome 1
Apply knowledge of
current practice and professional performance standards to the delivery of
contemporary psychiatric–mental health nursing.
Concepts for Lecture
1.
Psychiatric–mental
health nursing promotes mental health through assessment, diagnosis, and
treatment of human responses to mental health problems and psychiatric
disorders (ANA, APNA, ISPN, 2007). It is a specialized area of nursing practice that employs
theories of, and research on, human behavior as its science and the purposeful
use of self as its art. Essential components include: health and wellness
promotion through identification of mental health issues, prevention of mental
health problems, care of mental health problems, and treatment of persons with
psychiatric disorders (ANA, APNA, IPSN, 2007).
2.
In 1973, the
first standards of psychiatric–mental health nursing practice (ANA) serve as
guidelines for providing quality care. These standards delineate psychiatric–mental
health nursing roles and functions. ANA collaborated with the American
Psychiatric Nurses Association (APNA) and the International Society of
Psychiatric–Mental Health Nurses (ISPN) in 2000 and 2007 revisions.
3.
Two sets of
standards guide professional psychiatric–mental health nursing practice: Standards of Practice (see
Box 2-1Box 2-2
4.
Six
standards of practice describe a competent level of nursing care organized
around the nursing process:
a. Standard 1: Assessment—collects comprehensive
health data pertinent to the client’s health or situation.
b. Standard 2: Diagnosis—analyzes data to determine
diagnoses or problems, including level of risk.
c. Standard 3: Outcomes Identification—identifies
expected outcomes for a plan individualized to the client or to the situation.
d. Standard 4: Planning—develops a plan that
prescribed strategies and alternatives to attain expected outcomes.
e. Standard 5: Implementation—implements the plan.
i.
Standard 5A:
Coordination of Care
ii.
Standard 5B:
Health Teaching and Health Promotion
iii.
Standard 5C:
Milieu Therapy
iv.
Standard 5D:
Pharmacologic, Biologic, and Integrative Therapies
v.
Standard 5E:
Prescriptive Authority and Treatment (APRN only)
vi.
Standard 5F:
Psychotherapy (APRN only)
vii.
Standard 5G:
Consultation (APRN only)
f. Standard 6: Evaluation—evaluates progress toward
attainment of expected outcomes.
5.
The nine
standards of professional performance within the Standards of Practice describe
a competent level of behavior in professional role activities:
a. Standard 7: Quality of Practice— systematically enhances
the quality and effectiveness of nursing practice.
b. Standard 8: Education—attains knowledge and
competency that reflect current nursing practice.
c. Standard 9: Professional Practice Evaluation—
evaluates one’s own practice in relation to the professional practice standards
and guidelines, relevant statutes, rules, and regulations.
d. Standard 10: Collegiality—interacts with and
contributes to the professional development of peers and colleagues.
e. Standard 11: Collaboration—collaborates with clients,
families, and others in the conduct of nursing practice.
f. Standard 12: Ethics—integrates ethical provisions
in all areas of practice.
g. Standard 13: Research—integrates research findings
into practice.
h. Standard 14: Resource Utilization— considers factors
related to safety, effectiveness, cost, and impact on practice in the planning
and delivery of nursing services.
6. Standard 15: Leadership—provides leadership in the
professional practice setting and the profession.
Suggestions for Classroom Activities
·
Given the
ANA definition of psychiatric–mental health nursing (treatment of human
responses to mental problems or psychiatric disorders), ask students to list
examples of human responses psychiatric–mental health clients might exhibit and
thus would be areas for nursing care.
·
Lead a class
discussion asking students to identify specific nursing actions and situations
that demonstrate implementation of the standards of professional performance.
·
Ask students
to go to the ANCC link within the ANA Web site and report on the two levels of
certification for the psychiatric–mental health nurse.
- Ask students to go to the ANA or APNA Web sites and
find the links where the Psychiatric–Mental Health Nursing Standards of
Practice can be found.
Suggestions for Clinical Activities
·
Ask students
to compare their current nursing practice with the Psychiatric–Mental Health
Nursing Standards of Practice in order to identify areas of strength and areas
for needed improvement. Ask students to write an individualized plan to
strengthen areas needing improvement.
·
During
postconference, ask students to compare specific individual nursing actions or
behaviors during the clinical experience with the behaviors and actions as
outlined in the Psychiatric–Mental Health Nursing
Standards of Practice and ANA’s definition of psychiatric–mental
health nursing.
·
Ask students to compare and
contrast the role and responsibilities of the psychiatric–mental health nurse
in a variety of practice settings: hospital, home, clinic, community mental
health center, etc. .
Learning Outcome 2
Compare and contrast the
differences and similarities among the roles of the psychiatric–mental health
nurse and other members of the mental health team.
Concepts for Lecture
1.
The basic level
psychiatric–mental health nurse (PMH) may have received basic nursing
preparation in a diploma, associate degree, or baccalaureate program and is a
generalist who works in a specialized setting. The PMH nurse provides nursing
care through the nurse–client relationship and has major responsibility for the
milieu. Nurses at this level may seek certification as generalists through
ANA’s American Nurses Credentialing Center (ANCC).
2.
The advanced practice
registered nurse in psychiatric–mental health (APRN-PMH) is a licensed
registered nurse who is academically prepared as a clinical nurse specialist or
a nurse practitioner at the master’s or doctorate degree level in the specialty
of psychiatric– mental health nursing. APRN-PMH may seek certification at the
advanced level through ANCC and use the initials CS (certified specialist).
3.
The PMH nurse, an
integral part of the mental health team, is most likely to have an overall view
of the client’s situation. Role definitions that were traditionally assigned to
specific disciplines have become increasingly blurred. Mental health services
are provided by a variety of professionals. (See Table 2-1 in the textbook.)
a. The psychiatric–mental health nurses are responsible for
the nursing care of mental health clients; has major responsibility for the
milieu.
b. The psychiatrist is responsible for diagnosis and treatment
of persons with mental disorder.
c. The clinical psychologist performs psychotherapy; plans and
implements programs of behavior modification; and selects, administers, and
interprets psychological tests.
d. The psychiatric social worker helps clients and families
cope more effectively, identifies appropriate community resources, and may
perform counseling and psychotherapy.
e. The marriage and family therapist provides psychotherapy to
couples and families.
f. The occupational therapist uses manual and creative
techniques to elicit desired responses, teaches self-help activities, and helps
clients prepare to seek employment.
g. The recreational therapist plans and guides recreational
activities to provide socialization, healthful recreation, and desirable
experiences.
h. The creative arts therapist uses art, music, dance, and
literature to facilitate interpersonal experiences and increase social
responses and self-esteem.
i.
The psychosocial
rehabilitation worker teaches clients practical, day-to-day skills for living
in the community and provides case management services.
Suggestions for Classroom Activities
·
Ask
students, either individually or in small groups, to choose a member of the
mental health team and then lead a discussion of the specific activities and
responsibilities of the respective team member.
·
Provide
students with a clinical situation and ask a group of students to role-play the
perspective and contributions of each member of the mental health team.
Suggestions for Clinical Activities
·
Ask students
to interview a member of the mental health team regarding educational
preparation and the respective roles and responsibilities as mental health
services are delivered.
·
Ask students to identify
areas where certain roles and responsibilities are shared among various members
of the mental health team. Are the shared roles within the scope of practice?
Are they effective?
Learning Outcome 3
Analyze the factors that
influence the success with which the mental health team achieves collaboration
among its members and with clients and their significant others.
Concepts for Lecture
1.
Partnering
in cooperation and collaboration with others toward a common goal makes the
best use of the different abilities of mental health team members so that the
client and family receive the most effective service available. Inappropriate
competition hinders goal achievement and may be destructive. Partnership with clients
and families ensures informed consumers of mental health services.
2.
According to
game theorists, team members can be:
a.
Maximizers
(those interested only in their own gain) who jeopardize the client’s welfare.
b.
Rivalists
(those interested only in defeating their partners) who jeopardize the client’s
welfare.
c.
Cooperators
(those interested in helping both themselves and their partners) who facilitate
the work of the mental health care team by demonstrating respect and
recognizing the importance of individual members. Self-exploration and
self-assessment, through reading and dialogue with other nurses and team
members, can help embrace a spirit of cooperation.
3.
Lessons on
Collaboration (See Box 2-3 in the textbook):
a.
Know your
own reality: your values, biases, and goals.
b.
Value
diversity and turn differences into assets.
c. Acknowledge that conflict is natural and develop
skill with conflict resolution.
d. Recognize your own power base and share it with
others.
e. Master interpersonal communication skills and
processing skills.
f. Approach collaboration as lifelong learning.
g. Place yourself in interdisciplinary situations
whenever possible.
h. Appreciate that collaboration is often
spontaneous.
i.
Balance unity with autonomy—work neither
exclusively as a team member nor in isolation.
Suggestions for Classroom Activities
·
Ask students
to develop a personal plan for adopting a wider range of assertive and
collaborative behaviors in their professional life.
·
Lead a
classroom discussion of various communication techniques that enhance professional
communication and collaboration.
·
Ask students
to identify decisions that the nurse should make independently and those that
need to be made in collaboration with the mental health team.
·
Ask students
to identify personal values, biases, and cultural beliefs that might influence
their effectiveness when collaborating with members of the mental health team
and the variety of clients in mental settings.
Suggestions for Clinical Activities
·
Ask students
to observe the interaction and communication of various mental health team
members within the clinical setting. Have students identify effective and less
effective interactions and communication styles. Then ask students to role-play
approaches that are more effective.
·
During
clinical conference, have students practice giving nursing information to the
clinical group that is playing the role of the mental health team.
·
Role-play a
situation where two members of the mental health team disagree about a clinical
situation.
·
Ask students to identify examples of the mental
health team collaborating with clients and significant others.
Learning Outcome 4
Describe how the role of
the psychiatric–mental health nurse changed over the years from that of
custodian to a multifaceted role.
Concepts for Lecture
1.
The role of
the psychiatric–mental health nurse has changed over the years from that of
custodian to a multifaceted one, and practice settings have expanded from the
hospital to communities.
2.
Psychiatric–mental
health nursing in the 19th century:
a. First school of nursing, Kaiserwerth, was founded
in Germany
b. Florence Nightingale organized the Saint Thomas Hospital
c. In the early 1870s, the first three American
nursing schools opened in New York , Boston , and New
Haven
d. Linda Richards, “the first American psychiatric
nurse,” developed better nursing care in psychiatric hospitals and opened the
first American school for psychiatric nurses at McLean Psychiatric Asylum in
Waverly, Massachusetts in 1880.
e. The prevailing thought was that nurses caring for
clients with physical disorders should train in general hospitals and those
caring for clients with mental disorders should train in psychiatric hospitals.
f. Psychiatric nurses, only employed in asylums,
attended mainly to the physical needs of the clients and did not pursue
interpersonal work with them. Much of psychiatric nursing practice was
custodial, mechanistic, and directed by psychiatrists.
3.
Development
toward a more multifaceted role of psychiatric–mental health nurses in the 20th
century. Events of 1900–1940:
a. Ambiguity about professional psychiatric nursing
roles characterized 20th century.
b. School of nursing at Johns Hopkins
Hospital
c. First psychiatric nursing text not written by a
psychiatrist. Nursing Mental Diseases
was written in 1920 by Harriet Bailey.
d. Mental hospitals were seriously understaffed
during the years between the two world wars. In an effort to cope with
understaffing, mental hospitals opened schools of nursing at an incredible
rate.
e. In 1937, the National League for Nursing Education
(now the National League for Nursing) recommended that psychiatric nursing
content and clinical be a part of all basic nursing curricula. NLN begins to
standardize and accredit psychiatric nursing education in single-focus
psychiatric nursing schools.
4.
The mid to
late 20th century was a period of role clarification. Events of 1940–1990:
a. Nurses began to assume increasing responsibility
for educating nurses (1940s); the focus of psychiatric nursing activities
continued to be kind, but custodial.
b. In the 1940s, psychiatric theory expanded to
encompass the interpersonal and emotional dimensions of mental illness.
c. National Mental Health Act of 1946 is the most
significant piece of legislation affecting the development of psychiatric–mental
health nursing:
i.
Initiated
development of psychotherapeutic roles for nurses
ii.
Provided for
the establishment of the National Institute for Mental Health (NIMH)
iii.
Provided
funding for development of programs to train professional psychiatric
personnel, including psychiatric nurses
iv.
Support for
psychiatric research, and assistance in developing mental health programs
d. Nursing for the Future (Brown, 1948) recommended
elimination of single-focus schools for psychiatric nursing.
e. In 1955, NLN required psychiatric nursing
coursework and clinical in nursing schools seeking accreditation.
f. Hildegard Peplau published Interpersonal Relations
in Nursing (1952), the first systematic theoretic framework in psychiatric
nursing that delineated skills, activities, and roles and emphasized the
interpersonal nature of nursing and the need for nurses to use psychodynamic
concepts and counseling techniques.
g. Gwen Tudor (Will) published in the journal Psychiatry and demonstrated that nurses
can promote emotional growth in clients.
h. Frances Sleeper advocated the use of psychiatric
nurses as psychotherapists.
i.
Community
Mental Health Centers Act of 1963 encouraged closing of large mental hospitals
in favor of treatment in the community and encouraged the trend
toward more expanded and specialized roles in psychiatric–mental health
nursing. Clinical nurse specialists, prepared at the graduate level, began
providing individual, group, and family psychotherapy and obtaining third-party
reimbursement.
j.
Nurses began
publishing psychiatric nursing journals and textbooks advocating the counseling
role as the basis of psychiatric nursing:
i.
Perspectives in Psychiatric Care (1963)
ii.
Journal of Psychiatric Nursing and Mental Health
Services (in 1981 changed its
name to Journal of Psychosocial Nursing
and Mental Health Services)
iii.
American Journal of Nursing
iv.
Issues in Mental Health Nursing (1979)
v.
Archives of Psychiatric Nursing (1987)
vi.
Journal of the American Psychiatric Nurses
Association (1990s)
k. A 1967 ANA position paper on psychiatric nursing
endorsed clinical nurse specialists in the role of therapist in individual,
group, family, and milieu work. By the mid-1970s, certification at both the
generalist and specialist levels became the responsibility of the ANA.
l.
In 1973, ANA
published the first standards of psychiatric–mental health nursing practice to
serve as guidelines for providing quality care. Now revised several times, the
standards delineate psychiatric–mental health nursing roles and functions.
m. First nurse to play a major role in national
mental health policy was Martha Mitchell who participated in the 1977
Commission on Mental Health.
n. Major shift in psychiatric nursing thinking
occurred based on humanistic interactionism advocating negotiated goals between
nurse and client, client advocacy, political sensitivity, caring, and
compassion (Wilson & Kneisl, Psychiatric
Nursing, 1979).
o. Major concerns in the 1980s included the decrease
in the number of nurses selecting psychiatric nursing as a specialty and a
shortage of clinical training funding.
p. Psychiatric nursing diagnoses were developed and
incorporated into NANDA classification system in 1984.
5.
1990s—Decade
of the Brain included:
a. Integration of psychobiologic concepts with
traditional practice
b. Psychiatric–Mental Health Nursing
Psychopharmacology Project resulted in psychopharmacology guidelines
c. Political savvy in allocation of resources and
health care reform:
i.
Nursing roles in mental health care delivery
ii.
Mental
health promotion and mental illness prevention
iii.
Case
management
iv.
Holistic
perspective
v.
Equitable
access
1. Development of outpatient services including
private practice for nurses
2. Outcome-based research
3. Accurate image of psychiatric nursing
4. Emphasis of the human aspect of mental health work
5. Cultural diversity among psychiatric nurses
6. The new millennium (2000s):
a. Revisions of the standards of practice of
psychiatric–mental health nurses (ANA, APNA, ISPN) occurred.
b. There was a knowledge explosion in psychobiology:
biologic foundations of behavior, genetics, psychopharmacologic agents with
fewer side effects.
c. There is a renewed focus on the physical health
problems of psychiatric clients, especially those living in the community.
d. A trend is the shift to primary care as a point of
entry for psychiatric care.
e. A curriculum shift has occurred in graduate
programs toward comprehensive health assessment, management of common physical
health problems, and prescriptive authority for advanced practice nurses.
f. Settings for psychiatric–mental health nursing
continue to expand from hospitals and traditional settings to alternative and
nontraditional settings.
Suggestions for Classroom Activities
·
Break
students into small groups. Ask each group to research key events during
the emergence of psychiatric–mental health nursing presented in the text and
report to the class.
·
Ask
students, either individually or in small groups, to develop a poster
presentation explaining the impact of a key historical event on the emergence
of psychiatric–mental health nursing.
·
Ask students
to postulate reasons for the decline of the number of nurses choosing
psychiatric–mental health nursing as a practice specialty.
·
Ask students
to write a scholarly paper comparing and contrasting the practice of the
psychiatric–mental health nurse during the 19th and early 20th centuries with
the practice of today’s psychiatric–mental health nurse.
·
If possible,
ask students to review early psychiatric nursing texts that reflect a more
custodial role of the psychiatric–mental health nurse.
Suggestions for Clinical Activities
·
Since the mid-1970s,
the number of residents in state mental hospitals has declined. Ask students to
research their community to determine where these individuals currently live or
are treated.
·
Arrange a
visit to a psychiatric hospital that has a rich history and review historical
artifacts and documents giving a glimpse of the early role of the
psychiatric–mental health nurse.
- If possible, ask an older, retired psychiatric nurse
to describe psychiatric–mental health nursing practice as he or she
remembers it either as a nursing student or as a practicing nurse.
Learning Outcome 5
Discuss the nursing
theory concepts and principles that have shaped psychiatric–mental health
nursing most directly.
Concepts for Lecture
1.
Nursing theories assist
nurses to organize assessment data, identify problems, plan interventions,
generate goals and nursing actions,
and determine and evaluate outcomes.
2.
Early
nursing theories perpetuate psychiatric–mental health nursing values of
humanism, cultural competence, relevance of meaning, and empathy and
empowerment in the nurse–client relationship.
a.
Hildegard
Peplau, “the mother of psychiatric nursing,” conceptualized the one–to–one
nurse–client relationship with four phases: orientation, identification,
exploitation or working, and resolution.
b. Dorothea Orem identified universal self-care
requisites that included both physical and psychosocial human needs and focused
on the client’s abilities to perform self-care to maintain life, health, and
well-being.
c. Martha Rogers defined nursing as a holistic science of unitary
human beings and identified principles of hemodynamics, the notions of life processes, change, and human–environmental
interactions as central to nursing.
d. Sister Callista Roy’s adaptation theory views
people as psychosocial beings who are constantly faced with the need to adapt
to internal and external demands.
e. Ida Jean Orlando emphasized the importance of
deliberative nursing action based on the meanings that are validated between
the nurse and the client.
f. Ernestine Wiedenbach developed theory around the
client’s need for help, the validation of such need through client perceptions,
and the nurse’s role in observing, assessing, exploring, and validating
feelings, thoughts, and fears.
g. Joyce Travelbee focused on the meaning in
nurse–client interactions and explained sympathy, rapport, and suffering, and
emphasized communication and stages of the nurse–client relationship.
h. Paterson and Zderad urged that observations of the
experience of nurses in practice should be the basis of nursing theory and
incorporated an intersubjective transaction in which both the client and the
nurse are present in the experience in an existential way. The freedom of human
choice and responsibility are emphasized.
i.
Jean
Watson’s theory of human caring emphasizes a helping–trusting relationship that
incorporates the values of kindness, concern, love of self and others, and the
ecology of the earth. Her theory further emphasizes sensitivity to self, values
clarification, congruency, empathy, authenticity and genuineness, and the
client’s expression of emotions, suffering, and emphasized communication and stages
of the nurse–client relationship.
Suggestions for Classroom Activities
·
Ask students
to write their own philosophy of psychiatric–mental health nursing. Compare and
contrast it with the theories presented in this chapter.
·
Ask students
to develop a concept map examining the key concepts associated with a
particular nursing theory that has significantly impacted psychiatric– mental
health nursing.
·
Ask students
to develop a poster presentation of a particular nursing theory.
·
Lead a brief
discussion of each of the nursing theories, assisting students to identify specific nursing
assessments, goals, interventions, and evaluations that are consistent with the
respective theories.
·
Ask students
to go to the Web sites or homepages for the various nurse theorists that are outlined
in this chapter, and research the major concepts of each theory.
Suggestions for Clinical Activities
·
Either
individually or in small groups, ask students to choose one nursing theory
(presented in this chapter) and apply it to a client-care situation.
- Evaluate the mission, goals, values, and treatment
practices of the clinical agency and compare these to the nursing theories
presented in this chapter.
References
National Organization of
Nurse Practitioner Faculties. (2003). Psychiatric–mental
health nurse practitioner competencies.
Paterson,
J. G., & Zderad, L. T. (2007). Humanistic
nursing. Retrieved from http://www.paterson-zderad-humanistic-nursing.com
Watson Caring Science Institute. (2007).
Dr. Jean Watson’s Human Caring Theory:
Ten Caritas Processes. Retrieved from http://watsoncaringscience.org/caring.science/10caritas.html
Learning Outcome 6
Explain
why you should be capable of functioning in all theories of care.
Concepts for Lecture
1.
Nursing
theorists, especially Peplau, have laid the foundation for concepts central to
psychiatric–mental health nursing:
a. Differentiation of nursing from medicine with
emphases on caring and comforting rather than curing
b. Emphasis on the importance of interpreting meaning
c. Focus on interaction between the nurse and the client
d. Advocacy for the humanistic and existential values
of client dignity and nurse authenticity as crucial to quality of care
2.
Nursing approaches associated with two or more
different theories are often used in combination. This requires the nurse to be
capable of functioning according to a number of theories of care, depending on
which is best for the client, available resources, and limitations of the
situation. Application of various theoretical frameworks fosters
practice-oriented research and clinical judgments that can be articulated and
taught to others. Research is a tool for developing nursing theory that synthesizes
the most useful elements of previous theories.
Suggestions for Classroom Activities
·
Using
examples of client-care situations, ask students to identify which nursing theories
might be most effective in the nurse’s approach to the client.
·
Ask students
to write a scholarly paper explaining the value of nursing theories to the
practice of psychiatric–mental health nursing.
·
Lead a
discussion on the value of nursing theories to the practice of psychiatric–mental
health nursing.
Suggestions for Clinical Activities
·
Ask students
to correlate nursing actions and interventions during their clinical experience
with the respective nursing theory or combination of theories.
·
Ask students
to identify specific nursing interventions that correlate with the various nursing
theories as presented in this chapter.
·
Ask students to
present information from a research article that investigates the application
of a nursing theory to clinical practice.
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