Fundamental of Psychiatric Nursing.Dini

FUNDAMENTAL OF PSYCHIATRIC NURSING

Psychiatric nursing or mental health nursing is the speciality 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 additional training in psychological therapies, building a therapeutic alliance, dealing with challenging behavior, and the administration of psychiatric medication. 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.

Psychiatric had made great strides since the era of primitive medicine. However, the way the mind functioned remained largely an uncharted, undiscovered world. Franz Anton Mesmer (1734-1815), a controversial Austrian physician, presented a theory of mental operations that, although flowed, led toward the understanding of the workings of the mind. He claimed that through his mysterious powers called animal magnetism, he could cure a whole range a physical and mental disorders. He was able to provoke the appearance of symptoms in clients by his physical presence or by his gestures.

Psychiatric nursing in the United States is currently so strongly integrated with the rest of the nursing practice it may be hard to believe that 100 years ago general nursing and care of the mentally ill were completely separated. Readers of this textbook have probably assumed that a course in psychiatric mental health nursing would be part of their professional nursing education. Today, we have come to value the basic skills of mental health nursing as important for the nurse in the general hospital or clinic; and we have come to value the basic skills of physical assessment and management of physical health need as important skills for nurses in both inpatient and outpatient psychiatric setting. However, as nursing schools developed in the nineteenth century, a distinct difference arose between those who studied care for general patients in hospitals and graduated as “nurses” and those who studied care for the mentally ill graduated to be “mental nurses.” Only after several decades of separate education, schools, and employment did the notion that every nurse must have a background in psychiatric mental health care become fully realized in the United States. The purpose of this chapter is to provide a track the major developments that led to the recognition of psychiatric mental health nursing as an important nursing specialty in the United States. A brief historical overview of the treatment of mentally ill persons is presented, with a discussion of how this treatment evolved to the point where indeed ill and required both medical and nursing care.

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.

PSYCHIATRIC MENTAL HEALTH NURSING:AREAS OF PRACTICE

BASIC LEVEL FUNCION

Health promotion
Intake screening
Case management
Milieu therapy
Self-care activities
Psychobiological interventions
Health teaching
Crisis intervention
Counseling
Home visiting
Community action
Advocacy

ADVANCE LEVEL FUNCIONS

Psychotherapy
Psychobiological interventions
Prescriptive authority for drugs (in most states)
Clinical supervision/consultation
Liaison nursing

EVIDENCE-BASED PRACTICE

Evidence-based nursing practice has been defined as "the conscientious, explicit, and judicious use of the best evidence from systematic research to make decisions about the care of individual patients" (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Evidence-based practice involves putting the patient’s benefits first while continually striving to improve care through appropriate actions that are guided by scientific evidence (Gibbs, 2003).

Although evidence-based psychiatric care is relatively new for psychiatric nursing (Stuart, 2001), the notion of using scientific evidence in nursing practice dates back to the times of Florence Nightingale (1859/1969). Though not herself a psychiatric nurse, Florence Nightingale, the founder of the modern nursing profession, pioneered the use of statistics for evidence-based practice and used statistics to influence health care reform (Nightingale). In her early writings, Nightingale outlined the steps for assessing patient problems, developing hypotheses, collecting data, and analyzing it before designing nursing interventions (Nightingale). Like Nightingale, Hildegard Peplau (1952, 1988) believed that a scientific approach was essential to psychiatric nursing practice. Today, the development of evidence through clinical research is a high priority in psychiatric nursing (Haber, 2000).

The process of developing evidence-based nursing practice begins with a question about a specific patient problem or situation. A systematic search for evidence that could be used to answer the question follows. Once the evidence is obtained, its validity, relevance, and applicability are appraised. The evidence is then integrated with other information, including expert knowledge, patient preferences for alternative forms of care, and available resources. Taken together, these factors influence management of the clinical problem. Finally, the evidence-based practice decision is implemented and the outcome of the decision is evaluated (Stuart, 2001).Large randomized controlled trials and meta-analyses of studies providing evidence in a specific area are considered the "gold standards." These studies furnish the strongest and most powerful evidence for clinical practice.

Five levels of evidence used in practice have been identified (Stuart, 2001). The lowest level and least powerful evidence is provided by opinions of reviewers that are based on their experience and knowledge and constitute clinical practice guidelines. Somewhat stronger evidence is derived from opinions that come from well-known experts and respected authorities. Even more compelling evidence comes from the results of research studies. There are three levels of evidence derived from research. Non-randomized controlled studies or cohort studies provide the weakest evidence, while small randomized controlled trials yield evidence that is stronger and more influential. Large randomized controlled trials and meta-analyses of studies providing evidence in a specific area are considered the "gold standards." These studies furnish the strongest and most powerful evidence for clinical practice. Unfortunately, there is currently little psychiatric nursing research that meets this "gold standard" (Stuart, 2001), and the need for clearly defined areas of research priority for the psychiatric nursing specialty are apparent (Pullen, Tuck, & Wallace, 1999).

METHODS

To examine the quality of the currently available evidence for psychiatric and mental health nursing practice, we analyzed research conducted by psychiatric nurses and published in the five most commonly read psychiatric nursing journals published in the United States from January 2000 to January 2003. The five journals reviewed were: Archives of Psychiatric Nursing (Archives), Issues in Mental Health Nursing (Issues), Perspectives in Psychiatric Care (Perspectives), Journal of Psychosocial Nursing and Mental Health Services (JPNMHS), and the Journal of the American Psychiatric Nurses Association (JAPNA).Only data-based articles in these peer-reviewed journals were examined. The rationale for selecting the five most commonly read psychiatric specialty journals was to capture the types of research being disseminated to practicing psychiatric/mental health nurses. Our assumption was that nurses who were actively practicing in this field would be more likely to read these specialty journals than journals devoted specifically to research. Studies published in sub-specialty journals, such as those that address child and adolescent or geriatric psychiatry, were not included in the analysis.

PYSHICAL CARE

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

EVIDENCE fOR PSYCHIATRIC NURSING PRACTICE:WIVES’ TALES OR RESEARCH

Nursing practice has been influenced by traditional wisdom passed down through generations by word of mouth and in published textbooks. Without scientific evidence for practice, nurses have done the best they could in the patient’s interest. Much of the nursing care provided has been based on personal experience and the experiences of nurses and others who have gone before. Even today, much of psychiatric nursing practice is still grounded in tradition, unsystematic trial and error, and authority, rather than being based on sound empirical investigations (Wilson, 2004). Indeed, some psychiatric nursing knowledge comes from "Old Wives’ Tales," reflecting the perspectives of women from bygone days. This "received wisdom" is often taken for granted and passively implemented (Wilson). Although much of it is questionable, some of the wise sayings and beliefs passed down through the ages continue to contribute to many psychiatric nursing interventions.

Two landmark documents relevant for psychiatric nursing have recently been published by the U.S. Department of Health and Human Services (U.S. DHHS) Healthy People 2010, the National Health Promotion and Disease Prevention Objectives (2000), and the Report of the Surgeon General on Mental Health, submitted by David Satcher (1999). Both of these documents provide direction for psychiatric nursing and highlight the need for nursing practice based in evidence.

Many of the health care goals addressed within Healthy People 2010 (U.S. DHHS, 2000) are relevant to psychiatric mental health nursing. Objectives that are related to improvements in mental health include reduction of suicide rates in the general population, reduction of suicide attempts by adolescents, reduction in the number of homeless persons with severe mental illness, and increase in employment of persons with serious mental illness. Objectives related to expansion of treatment for the mentally ill include: reduction of relapse rates for persons with eating disorders; increase in mental health screening and assessment in primary care settings; increase in the numbers of children and adults with mental illness who receive treatment; increase in treatment for persons with dual diagnosis (including substance abuse); and increase in treatment for mentally ill persons in juvenile justice facilities and jails.

The Report of the Surgeon General on Mental Health (U.S. DHHS, 1999) was the first Surgeon General’s report ever published on the topic of mental health and mental illness. It was based on an extensive review of the scientific literature and consultation with mental health providers and consumers. This landmark document concluded that there are numerous effective treatments for most mental health disorders; but it also raises some questions for psychiatric nurses, including: (a) are psychiatric nurses aware of the efficacy of the treatments and interventions they provide? (b) are they truly practicing evidence-based psychiatric nursing? and (c) is there documentation of the nature and outcomes of the care they provide? (Stuart, 2000). The answers to these questions will shape the roles of nurses in a specialty area that is growing in its understanding of molecular and cell biology and genetics, as well as the cognitive and behavioral sciences.

PSYCHOSOSIAL 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 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.

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 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.

Psychiatric mental health nurses also work in forensic psychiatry with people who are detained as they have committed a crime or are particularly dangerous. People in the older age group who are more prone to dementia tend to be cared for in separate places than younger adults and there are also specialist services for the care of adolescents with mental health problems. Occasionally there have been efforts to integrate psychiatric units across the age spectrum.

THE ERA OF PSYCHIATRY

The dawning of the twentieth century in the United States found that improved societal attitudes promoted sensitivity toward the mentally ill. These changes endured and reflected society’s increasing concern for others. Likewise, legislators ultimately responded to these change by developing widespread measures for welfare reform and enacting child labor laws. These transformations encouraged medicine to take the lead and explore the basis of mental illness through scientific and clinical studies. Several major breakthroughs in the evolution of psychiatric care emerged during the twentieth century. Exploration of the reasons for mental disease accelerated with contributions from numerous theoreticians and researchers, who laid the foundation for understanding and demystifying mental illness.

PSYCHIATRIC MENTAL NURSING’S PHENOMENA OF CONCERN

Actual or potential mental health problems of clients pertaining to :

The maintenance of optimal health and well-being and the prevention of psychobiologic illness.
Self-care limitations or impaired functioning related to mental and emotional distress.
Deficits in the functioning of significant biological, emotional, and cognitive systems.
Emotional stress or crisis components of illness, pain, and disability.
Self-concept changes, developmental issues, and life process changes.
Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief.
Physical symptoms that occur along with altered psychological functioning.
Alterations in thinking, perceiving, symbolizing, communicating, and decision making.
Difficulties in relating to other.
Behaviors s and mental states that indicate the client is a danger to self or other or has a severe disability.
Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances or events that affect the mental and emotional well-being of the individual, family, or community.
Symptom management, slide affect/toxicities associated with psychopharmacologic intervention and other aspects of the treatment regimen.

Client on an acute psychiatric unit are there because they are ill and in need of supervision. Some, like susanna, are thought disordered and psychotic. Some are depressed and suicidal; some have been admitted to the unit after an attempt on their lives. Some have been admitted for drug detoxification or because of a drug-induced depression or psychosis. Each is a unique human being whose mental illness keeps him or her from functioning effectively in society.

Before we go on, we need to introduce some important concepts that will be considered in more depth in subsequent chapters. Psychosis means that the individual has lost the ability to recognize reality. A psychotic person may experience hallucinations, where he hears voices or sees images of person or things that other cannot see or hear. A psychotic person is frequently unable to care for his basic needs of safety, security, nutrition, and so on. Such as individual is hospitalized for his own safety and to initiate treatment (usually involving some form of medication) to bring his symptoms under control. A psychotic person may slip into and out of reality much as Kaysen described in her metaphor of parallel universes separated by an easily crossed membrane.

Persons who have a profound depression (feeling very sad, despondent, and with no energy and no sense of the future) are in treatment for their own safety, and it is the responsibility of the nursing staff to keep a depressed or suicidal patient from harming himself. Almost every student has some idea of how it feels to be depressed, to be down, to have no energy and no enthusiasm for activities, but few of us ever reach the profound depths of suicidal depression. Many hospitalized depressed persons are too despondent to talk or communicate except by occasionally echoing the words of other; some are catatonic, holding bizarre and rigid postures despite all attempts to move them. Depression of this degree seems untouchable, unreachable, and its treatment needs all the nurse’s resources of presence, patience, and caring.

SUMMARY

Historically, the treatment and the perception of the mentally ill have been influenced by religious and social norms. Treatment has varied from brutal, inhumane torture in asylums to community-based psychotherapy, psychiatric nurses did not exist before 1882, at which time McLean Asylum in Massachusetts began the first formal training of psychiatric nurses. The practice of psychiatric-mental health nursing has continued to evolve, and it has become far removed from that of custodian and controller. It has emerged as a specialty that requires the integration of neurobiological and behavioral concepts. McBride (1990) stressed that the future of psychiatric-mental health nurses hinges on their willingness to appreciate these concepts, develop research-based practice, and integrate caring into their practice. Psychiatric-mental health nurses can rise to the occasion by identifying clients at risk, participating in research endeavors to enhance practice, and developing effective treatment approaches. Overall, this process involves redefining the role of psychiatric-mental health nursing within a health care system in crisis and seeing nurses place themselves in key positions to direct client care.

REFERENCES:

Antai-Otong, Deborah. 1995. Psychiatric Nursing Biological and Behavioral Concept. Philadelphia: WB Saunders Company

Frisch Noreen Cavan and Frisch Lawrence. 2005. Psychiatric Mental Health Nursing, Third Edition. Thomson Delmar Learning

Varcarolis, Elizabeth M., Verna B.C. and Nancy C.S. 2006. Foundation of Psychiatric Mental Health Nursing: A Clinical Approach, Fifth Edition. Missouri: Saunders Elsevier

Stuart, Gail Wiscarz and Sandra J. Sundeen. 1995. Principles and Practice of Psychiatric Nursing, Fifth Edition. St Louis: Mosby Year Book Inc.

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