Chapter 1: Science and the Therapeutic Use of Self in Psychiatric Mental Health Nursing
Nursing integrates both science and art.
Science of Nursing: Finding the evidence for best practices.
Art of Nursing: Developing skills and the purposeful use of self.
Definition: “Psychiatric-mental health nursing, a core mental health profession, employs a purposeful use of self as its art and a wide range of nursing, psychosocial, and neurobiological theories and research evidence as its science.”
Evidence-Based Practice (EBP)
Definition: Clinical decision-making that synthesizes:
Best available research evidence
Clinical expertise
Patient preferences
Resources for Evidence-Based Interventions
Internet mental health resources
Clinical practice guidelines
Clinical algorithms and critical pathways
Clinical Algorithms
Definition: Step-by-step guidelines created in flowchart form.
Purpose: Describe alternative diagnostic and treatment approaches based on decisional points using a large database.
Example Application: Determining medication use based on personal patient factors such as age, sex, current medications, ethnic origin, and allergies.
Example: Clinical Algorithm for Suspected Suicide Risk
**Risk Factors:
Social isolation
Spiritual isolation
Male gender
Chronic medical illness
Chronic psychiatric illness
Substance abuse
Suicide plans**
Action Steps:
If one or fewer positive risk factors: Initiate medical management with close observation.
If two or more positive risk factors: Immediate psychiatric consultation.
Models: Evidence-Based Practice, Recovery, and Trauma-Informed Care
Recovery Model:
Consumers as partners in mental health care, which is family-driven.
Focus on increasing consumer capabilities such as adaptation, coping, recovery facilitation, and resilience.
Care plans are individualized, consumer-centered, and recovery-oriented.
**EBP History (1990s - Decade of the Brain):
Focus on scientific evidence for psychological and sociological treatments.
Neurobiology of psychiatric disorders and psychopharmacology influence practice.**
Trauma-Informed Care:
Highlights that trauma is common in mental health patients.
Shift focus from “What’s wrong with you?” to “What happened to you?” addressing trauma effects in treatment.
Emphasizes collaborative therapeutic relationships, empowerment, and cultural respect.
Hierarchy of Evidence
Level I: Systematic review or meta-analysis of RCTs
Level II: Well-designed RCTs
Level III: Controlled trials without randomization (quasi-experimental studies)
Level IV: Single nonexperimental studies (case-control, correlational, cohort studies)
Level V: Systematic reviews of descriptive or qualitative studies
Level VI: Single descriptive or qualitative studies
Level VII: Opinions of authorities or expert committee reports.
Research-Practice Gap
Description of the gap between the best evidence treatments and their effective translation into practice.
Emphasizes the need for continued research on applying findings to clinically relevant issues.
The Concept of Caring
Definition:
Caring is fundamental to nursing practice, seen as giving of self, leading to happiness, and evidenced through empathy and patience.
Important aspects of the caring nurse include:
Competence in knowledge and skills.
The absence of caring can be traumatic for patients.
Patient Advocacy
Definition: A patient advocate speaks up for and comforts another, aiding their health.
Advocacy roles in nursing include:
Committing to patient health.
Alleviating suffering.
Promoting a dignified death.
Nursing Advocacy: Not legal but ethical; nurses must act when patient rights are in jeopardy (American Nurses Association Code of Ethics).
Chapter 2: Mental Health and Mental Illness
What is the DSM-5?
Definition: The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, is the official guide for categorizing and diagnosing psychiatric mental health disorders in the U.S.
Provides a standard language and criteria for various stakeholders, including clinicians and policy makers.
Mental Health – Mental Illness Continuum
Seven Signs of Mental Health Wellness:
Happiness
Control of Behavior
Appraisal of Reality
Effectiveness in Work
Healthy Self-Concept
Satisfying Relationships
Effective Coping
Defining Mental Health
Definition of Mental Illness: "Mental illnesses are medical conditions resulting from dysfunctions of the brain and neurotransmission" - National Alliance on Mental Illness (NAMI).
Mental Illness Policy and Parity
Mental Health Parity Act (1996): Requires U.S. insurers to offer equal benefits for mental illness as for other conditions.
Improvements under the Affordable Care Act (ACA):
Banned annual dollar limits and eliminated pre-existing condition exclusions for mental health coverage.
Types of disorders with strong biological influences:
Schizophrenia, Major depression, Bipolar disorder, PTSD, Autism, Anorexia, ADHD.
Factors Affecting Mental Health
Biological Factors:
Hormonal and genetic influences.
Spiritual and Cultural Factors:
Religion, spirituality, community influences.
Environmental Experiences:
Childhood experiences, regional differences, and societal influences.
Negative Influences:
Psychosocial stressors including poverty and impaired parenting.
Myths and Misconceptions
Mental illness is often misunderstood:
No clear distinction exists between mental health and mental illness.
Cultural and societal norms influence definitions of mental illness.
Historical contexts: Women and gay individuals were pathologized as mentally ill due to societal biases.
Stigmatization Processes
Definition of Stigma: A negative stereotype causing perceptions of inferiority, danger, or instability in people with mental illness.
Stigmatizing attitudes hinder treatment and recovery and have adverse effects.
Psychosocial processes of stigmatization: Include stereotyping, labeling, discrimination, and social isolation.
DSM Diagnosis Considerations
DSM classifies a disorder without labeling the individual; encourages the use of terms like “individual with schizophrenia” rather than derogatory labels.
DSM-5 vs. Nursing Diagnosis Comparison
DSM-5 Diagnosis: Defines mental disorders tied to psychological/behavioral patterns, leading to distress or disability. It is seen as a foundational tool for mental health practitioners.
Nursing Diagnosis: Based on the International Classification for Nursing Practice (ICNP), allows identification of nursing diagnoses and interventions specific to mental health.
Cultural Influences on DSM-5 Diagnosis
Cultural factors affect symptom perception, coping abilities, and help-seeking behaviors. The DSM-5 addresses cultural contexts in:
Variations for clinical disorders, culture-bound syndromes, and evaluating cultural impact on mental health.
Chapter 3: Theories and Therapies
Chapter Objectives
Discuss contributions of theories and therapies across disciplines.
Choose two relevant theories in psychiatric nursing and defend their importance.
Identify origins and developments of dominant theories and treatments.
Discuss the relevance of theories/treatments in psychiatric care.
Demonstrate understanding of Peplau’s theoretical contributions to practice.
Identify different theoretical models for patient care.
Distinguish clinical care models and their benefits/limitations.
Theories and Therapies
Late 1800s: Emergence of psychologic models influenced mainstream understanding of mental health and illness.
Freud's Psychoanalytic Theory
Personality Structure:
Id: Focuses on pleasure principle, reflex action, and primary processes.
Ego: Functions to solve problems and test reality.
Superego: Represents the moral component.
Levels of Awareness: Includes conscious, preconscious, and unconscious.
Defense Mechanisms: Operate unconsciously to protect from anxiety by distorting reality.
Importance in Nursing Practice
Individual talk sessions and psychodynamic therapy play critical roles in addressing mental health issues.
Key elements include attentive listening, transference, and countertransference.
Erikson's Eight Stages of Development
Personality evolves throughout life; failures in one stage can be addressed in subsequent stages.
Stages include Trust vs. Mistrust, Autonomy vs. Shame, Initiative vs. Guilt, and others concluding with Integrity vs. Despair.
Sullivan's Interpersonal Theory
Proposes that behavior's purpose is to meet needs through social interactions and to reduce anxiety.
Therapeutic Model: Involves active guidance from therapists as participant observers.
Behavioral Theory
Key Theorists: Pavlov, Watson, Skinner.
Emphases on behavior modification, systematic desensitization, aversion therapy, and biofeedback in nursing interventions.
Cognitive Theory
Focus on stimulus-appraisal-response relationships.
Rational-Emotive Behavior Therapy (REBT): Aims to eliminate irrational beliefs and alter thought patterns.
Cognitive-Behavioral Therapy (CBT): Focuses on modifying negative thoughts leading to dysfunctional emotions.
Mental processes originate in brain activity; psychotherapy is linked to measurable brain changes.
Most effective therapies for modifying brain function: CBT, DBT, psychodynamic psychotherapy, interpersonal therapy.
Other Major Theories
Cognitive Development (Piaget)
Psychosocial Development (Erikson)
Theory of Object Relations (Mahler)
Theories of Moral Development
Lawrence Kohlberg: Moral development theory progresses through pre-conventional, conventional, and post-conventional stages.
Carol Gilligan: Critique emphasizing ethics of care in contrast to traditional moral development.
Nursing Theories Development
1950s Shift: From hospital-based programs to university programs; emergence of research in nursing theories, especially those relevant to psychiatric nursing.
Interpersonal Relations in Nursing
Hildegard Peplau: Credited as the "mother of psychiatric nursing," influenced by Sullivan's work.
Peplau’s Theory Characteristics:
Levels of anxiety (mild, moderate, severe, panic).
Four phases in therapeutic relationships including mutual respect and unconditional acceptance.
Influence of Theories on Nursing Care
Behavioral theories focus on adaptive behavior reinforcement.
Cognitive strategies aid in identifying and addressing negative thought patterns.
Psychosocial theories offer frameworks for navigating developmental challenges.
Mental Health Recovery Model
Emphasizes adaptive living; patient-centered goals and responsibilities include listening and respecting patient desires. Focus areas include:
Hope, social connection, empowerment, coping strategies, and finding meaning in life.
Group Therapy
Defined by face-to-face interactions aimed at a common goal, incorporating:
Group characteristics, dynamics, leadership styles, and benefits.
Common types led by nurses include: medication education, dual-diagnosis groups, symptom management, stress management, and self-care.
Additional Therapy Modalities
Milieu Therapy: Focuses on the total environment including people, setting, structure, and emotional climate.
Family Therapy Goals
Reduce dysfunctional behavior and family conflicts.
Mobilize resources and improve communication skills.
Prepare family members for coping with stressors and promote system integration within society.
Chapter 5: Settings for Psychiatric Care
Overview of Treatment Settings
Treatment for mental disorders is often perceived as confusing with misconceptions about the nature of mental illness impacting care-seeking behaviors.
Historical Evolution of Treatment Settings
Asylums: Established for the "insane" before the Civil War.
1940s-50s: Introduction of psychotropic medications and options for care (psychologists and hospitals).
1960 Great Society Reform: Decline in state-run hospital populations, rise of community care systems post-Medicare and Medicaid.
1999 Olmstead Decision: Supreme Court ruling against unjustified isolation in psychiatric hospitals, promoting community care.
Treatment Environments
Inpatient Settings:
24-hour nursing care in locked units for safety.
Crisis care in residential treatment programs and general hospital psychiatric units.
Outpatient Settings:
Primary care providers and community mental health centers supporting patient-centered medical homes.
Mental Health Professionals' Roles
Insight into multidisciplinary treatment teams:
Roles for nurses, psychiatric nurse practitioners, mental health technicians, occupational and recreational therapists, physician assistants, psychiatrists, and psychologists.
Specialty Treatment Settings
Including pediatric psychiatric care, geriatric psychiatric services, forensic psychiatric centers, and drug/alcohol abuse treatment programs.
Role of Consumers in Mental Health
Consumers are individuals utilizing mental health services along with their families.
Organizations like NAMI emphasize self-help and recovery while advocating for treatment and policy reforms.
Financing Psychiatric Care
Resources for Care: Private insurance, Medicaid, Medicare, SSDI, and SSI.
Overview of legislation impacting mental health funding:
Mental Health Parity Act (1996): Ensures the same level of care as provided for physical health.
Affordable Care Act (2010): Enhancements to mental health coverage and elimination of restrictions for mental illness care access.