midterm 1

Ch 1: Mental Health and Mental Illness

Understanding Mental Health

• Mental health involves recognizing potential, coping with stress, and contributing to the community.

• It enhances life enjoyment while respecting culture, equity, and dignity.

• Key attributes include rational thinking, effective communication, emotional growth, and resilience.

• Good mental health leads to better physical health outcomes and improved educational and economic participation.

Cultural Influences on Mental Health

• Culture encompasses various aspects including age, gender, and socioeconomic status, influencing mental health perceptions.

• Mental health definitions vary across cultures, affecting behavior in different group sizes.

• Societal norms play a significant role in how mental illness is categorized and treated.

Mental Illness Overview

• Mental illness is characterized by disorders with definable diagnoses and significant dysfunction in mental functioning.

• The Diathesis-Stress Model explains how genetic vulnerability and environmental stressors contribute to mental health issues.

• Early experiences can shape future behaviors, as illustrated by attachment styles formed in childhood.

Resilience in Mental Health

• Resilience is the ability to recover from stress and secure resources for well-being.

• Key characteristics include optimism, a sense of mastery, and competence.

• Resilience is essential for recovery and maintaining mental health.

Chapter 2: Historical Overview of Psychiatric Mental Health Nursing

Evolution of Psychiatric Care

• Until the 19th century, mentally ill individuals were cared for at home or in poor conditions.

• Early asylums emerged in the 15th century, often run by laypeople without medical training.

• The rise of the middle class and Enlightenment ideas shifted perceptions towards humane treatment.

Moral Treatment Movement

• The moral treatment approach emerged in the late 18th century, focusing on compassion and humane care.

• Philippe Pinel advocated for humane treatment, removing chains and abusive practices in asylums.

• This movement led to the establishment of purposefully designed asylums with rehabilitative attitudes.

Development of Asylums in Canada

• New Brunswick opened the first mental institution in 1835, marking a shift in care for the mentally ill.

• Each Canadian province established its own asylum following the British North American Act of 1867.

• The 'Insanity Act' was passed to support the confinement of mentally ill individuals, later updated to the 'Mental Health Act'.

Advocacy and Social Reform

• Dorothea Lynde Dix was a key advocate for humane treatment of the mentally ill in the 19th century.

• Her efforts highlighted the poor conditions in institutions and pushed for state-supported public care.

• Despite social reforms, conditions in asylums often remained poor due to overcrowding and limited resources.

Historical Figures in Psychiatric Care

Dorothea Lynde Dix (1802-1887):

Social reformer and advocate for state-supported public care.

·        Led a crusade for humane treatment of the mentally ill in North America in the 19th century

·        Was told by a jailer, "the insane need no heat" when she questioned the lack of heating in winter.

Thomas Clarke (1857-1924)

• Superintendent of Ontario psychiatric hospitals, improved institutional conditions.

• Introduced nurse training for asylum personnel, enhancing care quality.

• Advocated for urban centers for acute mental illness treatment, leading to the establishment of the Toronto Psychiatric Hospital in 1925.

• The institution evolved into the Clarke Institute of Psychiatry in 1966, now known as CAMH.

Clifford Beers (1876-1943)

• Authored 'A Mind That Found Itself' in 1908, detailing his traumatic experiences in various hospitals.

• Advocated for psychiatric care reform, influenced by neuropathologist Adolf Meyer.

• His experiences highlighted the need for humane treatment and better care standards.

Core Values and Ethical Principles in Nursing

Commitment to Patient Well-being

• Nurses prioritize the well-being of their patients, ensuring safe and compassionate care.

• Ethical care involves competence and adherence to professional standards.

Code of Ethics for Registered Nurses (RNs)

• Seven core values guide RNs: safe care, health promotion, informed decision-making, dignity, privacy, justice, and accountability.

• Each value carries specific responsibilities that nurses must uphold.

Ethics vs. Morals

• Ethics: External guidelines dictating behavior based on societal norms.

• Morals: Personal beliefs shaped by culture and upbringing, guiding individual behavior.

Six Principles of Bioethics

• Autonomy: Respecting patients' rights to make informed decisions.

• Nonmaleficence: Obligation to avoid harm to patients.

• Beneficence: Duty to promote good and well-being.

• Justice: Fair distribution of resources and care.

• Principle of Impossibility: No obligation when circumstances prevent action.

• Fidelity: Commitment to loyalty and trust in the nurse-patient relationship.

Relational Ethics and Nurse-Client Relationships

Understanding Relational Ethics

• Emphasizes mutual respect, engagement, and interdependence in nursing.

• Recognizes the importance of therapeutic relationships in patient care.

Components of Nurse-Client Relationships

• Trust: Essential for effective care and communication.

• Respect: Acknowledging the dignity and uniqueness of each patient.

• Professional Intimacy: Building closeness through care activities.

• Empathy: Understanding and validating patient feelings.

• Power Dynamics: Awareness of professional authority over patients.

Ethical Action in Nursing

• Involves context, relationships, and emotional understanding.

• Requires active listening and validation of patient feelings.

Mental Health Legislation and Human Rights

Overview of Mental Health Legislation

• Governed by international and national human rights standards.

• Provincial laws vary regarding treatment rights and involuntary admissions.

Human Rights in Mental Health

• Recognition of dignity and worth as fundamental rights.

• Key rights include equality, privacy, autonomy, and freedom from inhumane treatment.

Patients' Rights Under the Law

• Right to treatment and to refuse treatment.

• Informed consent and competency are essential.

• Community treatment orders and least restrictive care principles.

Theoretical Approaches to Ethics in Nursing

Ethical Frameworks

• Deontology: Focus on duty and principles, emphasizing intent over outcomes.

• Utilitarianism: Actions are judged by their consequences for the greatest number.

• Virtue Ethics: Emphasizes character and moral virtues in decision-making.

Additional Ethical Approaches

• Casuistry: Case-based reasoning informed by past decisions.

• Principlism: Balancing ethical principles in decision-making.

• Ethics of Care: Focus on relationships and care as central to ethical practice.

Ethical Principles in Mental Health Care

Key Concepts of Principlism

• Non-maleficence: Obligation to avoid causing harm to patients.

• Beneficence: Duty to promote good and improve patient well-being.

• Respect for autonomy: Acknowledging and supporting a patient's right to self-governance.

• Justice: Ensuring fairness in the distribution of healthcare resources and risks.

Ethics of Care and Feminist Ethics

• Ethics of Care: Focuses on relational responsibilities and emotional responsiveness in care.

• Feminist Ethics: Addresses power imbalances and advocates for social justice in healthcare.

• Emphasizes the importance of empathy and emotional connections in patient care.

Overview of Mental Health Legislation

Criminal Code and Mental Disorders

• Distinction between mental health legislation and criminal law.

• Legal provisions for treatment compliance as probation conditions.

• Not Criminally Responsible (NCR) status due to mental disorders.

• Monitoring by Criminal Code Review Boards for NCR individuals.

Medical Assistance in Dying (MAiD)

• Definition of MAiD and its legal framework.

• Criteria for eligibility: serious illness, irreversible decline, intolerable suffering, and foreseeable death.

• Exclusion of mental illness as the sole condition for eligibility.

• Importance of informed consent and competence in decision-making.

Ethical Issues in Psychiatric and Mental Health Nursing

Patient Autonomy and Decision-Making

• Psychiatric Advance Directives (PADs) as a legal resource.

• Surrogate designation for decision-making support.

• Importance of communication tools to avoid involuntary treatment.

• Role of nurses in supporting PAD preparation and patient autonomy.

Documentation and Record Keeping

• Importance of accurate and complete medical records.

• Use of records for quality improvement and legal evidence.

• Electronic documentation retention policies (10 years).

Moral Dilemmas and Distress in Nursing

Understanding Moral Dilemmas

• Definition of moral dilemmas and moral distress.

• Examples of conflicts in moral obligations in nursing practice.

• Impact of internal and external constraints on moral choices.

Threats to Patient Dignity

• Challenges in supporting patients during emotional outbursts.

• Ethical considerations in timely care provision.

• Risks of punitive measures and behavior control (restraints, seclusion).

Therapeutic Relationships and Boundaries

Importance of Boundaries

• Definition and significance of boundaries in therapeutic relationships.

• Ethical complexities surrounding boundaries (gifts, social media).

• Awareness of transference and countertransference in nursing practice.

Cultural Considerations in Mental Health

• Impact of culture, race, and ethnicity on health determinants.

• Importance of cultural safety and trauma-informed practice.

• Understanding the role of colonization in health disparities.

Understanding Ethnicity and Cultural Contexts

Ethnicity vs. Race

• Race is defined by physical traits, while ethnicity encompasses cultural identity.

• Ethnicity includes shared cultural practices, perspectives, and distinctions that set groups apart.

Cultural Views Impacting Mental Health Care

• Western Tradition emphasizes individualism and biomedical approaches.

• Eastern Tradition focuses on holistic and community-oriented practices.

• The Medicine Wheel represents Indigenous perspectives on health and balance.

Key Concepts in Cultural Interaction

• Enculturation is the gradual acquisition of cultural norms by individuals from different backgrounds.

• Ethnocentrism leads to the belief that one's own culture is superior, affecting interactions with others.

• Cultural imposition occurs when one culture forces its beliefs onto another without consideration.

Mental Health Concerns in Diverse Populations

Indigenous Peoples' Mental Health Issues

• Intergenerational trauma significantly impacts mental health outcomes.

• High rates of hopelessness and suicide are prevalent in Indigenous communities.

• Family violence and substance use are critical concerns requiring culturally relevant services.

Refugees and Mental Health

• Refugees often experience post-traumatic stress and adjustment disorders.

• Depression and distrust of authorities are common mental health challenges.

• There is a need for services that accommodate language barriers and cultural differences.

Barriers and Facilitators in Mental Health Care

Barriers to Accessing Care

• Stigma and discrimination hinder individuals from seeking help.

• Communication barriers extend beyond language, affecting understanding and trust.

• Misdiagnosis can occur due to cultural concepts of distress.

Facilitators for Effective Care

• Cultural competence in nursing is essential for effective patient interactions.

• Understanding genetic variations can improve treatment responses.

• Utilizing professional interpreters can enhance communication and care quality.

Recovery and Treatment Approaches for Serious Mental Illness (SMI)

Rehabilitation vs. Recovery

• Rehabilitation focuses on managing deficits and living with illness.

• Recovery emphasizes achieving personal goals and leading meaningful lives.

Issues Confronting Individuals with SMI

• Comorbid conditions complicate treatment and recovery efforts.

• Stigma and social isolation are significant barriers to recovery.

• Economic challenges, such as unemployment and housing instability, impact mental health.

Nursing Process and Standards of Care

The Nursing Process in Mental Health

• The nursing process is a six-step approach to provide quality care: assessment, diagnosis, planning, implementation, evaluation, and documentation.

• Language barriers necessitate the use of professional translators for accurate assessments.

Assessment Strategies

• Gathering information from multiple sources, including family and caregivers, is crucial for accurate assessment.

• Creating a low-anxiety environment is essential for effective patient interviews.

• Special considerations are needed when assessing children, including potential regression in behavior.

Standard 1: Assessment

Key Concepts

Assessment is crucial in understanding patient needs and conditions.
Language barriers may necessitate the use of professional translators to avoid misunderstandings.
Primary sources of assessment include the patient, while secondary sources can include family and healthcare team members, requiring patient consent.

Assessment of Children

Gather information from both the child and caregivers, as caregivers can interpret the child's behavior.
Regression in psychiatric disorders may manifest as unusual behaviors, such as thumb-sucking in older children.
Methods include interviews, observations, and therapeutic play to uncover concerns.

Assessment of Adolescents

Privacy and confidentiality are essential; adolescents need assurance that their disclosures are protected.
A nonjudgmental approach is necessary when discussing sensitive topics like substance use and sexual activity.
The HEADSSS psychosocial interview technique is used to assess various aspects of an adolescent's life.

Assessment of Older Adults

Aging can lead to declines in sensory and cognitive functions; avoid stereotyping older adults.
Identify and accommodate physical deficits to reduce anxiety during assessments.
Effective communication strategies include speaking clearly and maintaining appropriate personal space.

Standard 2: Nursing Diagnosis

Key Components

The nursing diagnosis consists of three components: problem (unmet need), etiology (probable cause), and supporting data (signs and symptoms).

Standard 3: Outcomes Identification

Outcome Criteria

Outcomes should reflect the highest level of patient health achievable through nursing interventions.

Standard 4: Planning

Principles of Care Planning

Care plans should be safe, compatible with other therapies, realistic, individualized, and evidence-informed.
For example, planning for a patient at risk for suicide may include specific interventions like suicide precautions.

Standard 5: Implementation

Basic Interventions

Coordination of care is essential, with nurses documenting the implementation of care plans.
Health teaching should be adapted to the patient's needs, integrating current knowledge and research.
Milieu therapy focuses on creating a therapeutic environment for patient comfort and safety.

Standard 6: Evaluation

Systematic Evaluation

Evaluation is a continuous process to assess if outcome criteria have been met.
Ongoing assessments allow for adjustments to nursing diagnoses and interventions as needed.

Understanding Suicide

Definition and Context

• Suicide is the intentional act of killing oneself, recognized as a major cause of premature death.

• Historical terms like 'commit suicide' are being replaced with more acceptable terms such as 'death by suicide'.

• The societal shift towards understanding suicide as a public health issue rather than a moral failing.

Biological and Cultural Factors

• Low serotonin levels are linked to depression and suicidal behavior.

• 5-HIAA levels in cerebrospinal fluid may predict suicidal tendencies.

• Cultural factors such as religious beliefs and family values significantly influence suicide rates.

Assessment and Nursing Process

• The nursing process includes assessment of verbal and nonverbal clues indicating suicidal ideation.

• Tools like the SAD PERSONS scale help in evaluating suicide risk.

• Effective communication is crucial; asking direct questions about suicidal thoughts can be relieving for the individual.

Non-Suicidal Self-Injury (NSSI)

Definition and Purpose

• NSSI involves self-inflicted injuries without the intent to end life, often as a coping mechanism for emotional pain.

• Common methods include cutting, burning, and hitting oneself.

Nursing Interventions

• Assessment of injuries and building a therapeutic relationship are essential.

• Promotion of adaptive coping strategies and problem-solving skills is crucial for recovery.

• Setting clear boundaries and limits is necessary to maintain a therapeutic relationship.

Trauma and Its Effects

Understanding Trauma

• Trauma is a lasting emotional response to distressing events, which can be single or repeated experiences.

• It can have personal or collective implications, affecting mental and physical health.

DSM-5 Criteria for PTSD

• PTSD can develop from exposure to death, serious injury, or sexual violence, either directly or indirectly.

• Not all individuals affected by trauma will meet the criteria for PTSD, but they may still experience significant effects.

Reactions and Long-term Effects

• Trauma can alter perception, emotional processing, and interpersonal interactions.

• Persistent reactions may include fear, helplessness, and attachment issues, impacting long-term mental health.

Understanding Trauma

Types of Trauma

• Developmental Trauma: Also known as Complex Trauma, it involves chronic exposure to adverse experiences during childhood.

• Adverse Childhood Events (ACEs): Includes abuse, neglect, and household challenges that can lead to long-term emotional and physical health issues.

Impact of Trauma on Development

• Repeated exposure to trauma can compromise emotional management in later life.

• Erikson’s Stages of Psychosocial Development highlight how early experiences shape adult behavior and trust issues.

Brain Development and Trauma

• Childhood trauma affects the structure and function of the brain, particularly areas like the thalamus, hippocampus, hypothalamus, and amygdala.

• The brain develops from the bottom up, with survival functions being prioritized over higher cognitive functions.

Effects of Trauma

Emotional and Behavioral Effects

• Emotional effects include depression, anxiety, and feelings of hopelessness.

• Behavioral effects may manifest as self-harm, substance misuse, and perfectionism.

Cognitive and Relational Effects

• Cognitive effects can lead to memory lapses, overthinking, and difficulty making decisions.

• Relational effects include challenges in trusting others and maintaining close relationships.

Physical Health Consequences

• Trauma can increase the risk of chronic illnesses such as cancer, heart disease, and gastrointestinal disorders.

• Long-term stress can lead to allostatic load, affecting various bodily systems.

Mechanisms of Stress Response

Types of Stress Responses

• Positive Stress: Normal and essential for development, involving brief increases in heart rate.

• Tolerable Stress: More severe but manageable stress that activates the body's alert systems.

• Toxic Stress: Prolonged and severe adversity that overwhelms coping mechanisms.

Homeostasis and Allostasis

• Homeostasis: The body's optimal functioning state, maintaining balance in bodily functions.

• Allostasis: The process of adapting to changes, predicting needs, and managing stress.

Protective Factors and Resilience

Factors Influencing Trauma Outcomes

• Protective factors such as healthy caregiver-child attachment and social connections can mitigate trauma effects.

• Not all individuals exposed to trauma develop PTSD, indicating resilience in some cases.

Polyvagal Theory

• Explains the autonomic nervous system's role in stress responses, including fight or flight.

• The vagus nerve has two branches: the ventral vagal branch (social engagement) and the dorsal vagal branch (immobilization responses).

Neurobiological Effects of Trauma

Stress Hormones and Their Impact

• Overproduction of stress hormones leads to jitteriness and an exaggerated startle response.

• The brain's alarm system remains active, complicating the interpretation of others' behaviors, often perceived as threatening.

• Triggers involuntary fight/flight/freeze responses, affecting daily functioning.

Manifestations of Trauma in the Workplace

• Trauma effects vary among individuals, leading to lateness or absenteeism.

• Explosive outbursts and negative interactions can disrupt workplace harmony.

• Difficulty in task performance and increased errors are common signs of trauma impact.

Re-traumatization and Its Effects

Understanding Re-traumatization

• Trauma can lead to flashbacks, intrusive thoughts, and distressing dreams.

• Triggers related to the trauma can provoke physiological reactions.

• Avoidance of reminders of the trauma can lead to social isolation.

Unpredictability of Reactions

• Reactions to triggers can be unpredictable, complicating interactions.

• Individuals may experience distress without clear cause, affecting workplace dynamics.

Secondary Trauma and Compassion Fatigue

Definitions and Risk Factors

• Secondary trauma occurs from exposure to others' trauma, leading to similar symptoms.

• Risk factors include repeated exposure, personal trauma history, and lack of support systems.

Signs of Compassion Fatigue

• Symptoms include reduced efficacy, concentration issues, and emotional numbness.

• Isolation, withdrawal, and exhaustion are common signs of compassion fatigue.

• Jaded perspectives and secretive self-medication may arise.

Trauma-Informed Care Principles

Understanding Trauma-Informed Care

• A trauma-informed approach is about relationships rather than a checklist.

• The 4 Rs framework: Realize, Recognize, Respond, Resist.

Importance of Being Trauma-Informed

• A significant portion of individuals are affected by trauma, impacting workplace dynamics.

• A compassionate approach enhances engagement, retention, and productivity.

• Mitigates effects of trauma, reducing chances of PTSD, anxiety, and improving overall wellness.

Core Principles of Trauma-Informed Care

Key Principles

• Safety: Ensuring physical and emotional safety in interactions.

• Trustworthiness & Transparency: Building trust through transparent decision-making.

• Peer Support: Integrating shared experiences into service delivery.

Empowerment and Collaboration

• Empowerment: Building on individual strengths and fostering resilience.

• Collaboration: Leveling power differences to support shared decision-making.

Commitments of Trauma-Informed Organizations

Seven Commitments

• Non-violence: Building safety skills and commitment to a higher purpose.

• Emotional Intelligence: Teaching emotional management skills.

• Open Communication: Overcoming barriers to healthy communication.

Teaching Skills for Patients

• Focus on self-soothing, self-trust, and self-compassion.

• Emphasize self-regulation and limit setting in interactions.