Nursing 304

Frameworks and Basic Concepts

for Providing Nursing Care to
Clients and Families Experiencing
Psychiatric Disorders
 Mental Health
 --”is defined as successful
performance of mental functions,
resulting in the ability to engage in
productive activities, enjoy fulfilling
relationships, and change or cope
with adversity” (p. 2)
 Mentally Healthy
 A person is mentally healthy when a
person possesses knowledge of oneself;
meets one’s basic needs; assumes
responsibility for one’s behavior and for
self-growth; has learned to integrate
thoughts, feelings, and actions; and can
resolve conflicts successfully.
 A mentally healthy person maintains
relationships, communicates directly
with others, and respects others.
 A mentally healthy person adapts to
change in one’s environment.
 Mental Illness
 -- “is considered a clinically
significant behavioral or
psychological syndrome experienced
by a person and marked by distress,
disability, or the risk of suffering
disability or loss of freedom” (p. 2)
 Mentally Ill
 The mentally ill show deficits in
functioning; it is usually these deficits
that bring them to the facilities where
you will encounter them.
 Mental illness occurs when an individual
is not able to view oneself clearly or has
a distorted view of self, is unable to
maintain satisfying personal
relationships, and is unable to adapt to
one’s environment.
 The American Psychiatric Association
defines mental disorder as “clinically
significant behavior or psychological
syndrome or pattern that occurs in an
individual and is associated with present
distress (i.e., negative response to
stimuli that are perceived as
threatening) or disability (i.e.,
impairment increased risk of suffering,
death, pain, disability, or an important
loss of freedom).
 Mental Health Versus
Mental Illness
Signs of Mental Health Signs of
Mental
Illness

(See Table 1-1, p. 5)

Prevalence of Psychiatric
Disorders in the United
States

(See Table 1-2, p. 7)

 Chapter 2: Psychiatric Nursing
Evolution of a Specialty
 Care of the Mentally Ill
 Early Civilization
 The insane were treated through magical
rituals, prayer, and exorcism.
 The Greek and Roman cultures developed
ideas of body “humors” – blood, black bile,
yellow bile, and phlegm-which could
influence emotional stability.
 Hippocrates believed that excesses of black
bile caused melancholy and that
bloodletting could remove this excess.
 Middle Ages and Renaissance
 The term “lunatic” emerged to refer to one
controlled by the lunar body.
 Treatment of the mentally ill was influenced
by beliefs that the mentally ill were evil,
witches, or heretics.
 The mentally ill were excluded from
community life or institutionalized.
 Care was custodial and were poorly fed and
clothed and were restrained.
 Eighteenth and Early Nineteenth
Centuries
 The mentally ill were committed to asylums.
 They were place in prison if they committed
a crime.
 Their care was performed by persons
without training or interest in helping others
and was often lacking in compassion.
 A few physicians in the U.S. and England
began to view the insane as persons
suffering disease and needing some kind of
treatment.
 English physician William Battie’s word elevated
mental services to something respectable
physicians could do. He also believed that the
care of the mentally ill should be done by
carefully selected and trained.
 Insanity was viewed as a disease.

 Physicians began to classify mental disorders.

 They described moral and physical causes of

mental illness.
 In 1846, the term psychiatry was introduced by
physicians and they published their work in The
Journal of Mental Science.
 Asylums were built for the treatment and
cure of the insane.

-Nineteenth Century
 Conditions in the asylums became
unbearable.
 There was a called for reform.

 Dorothea Lynde Dix became a leader for

reform. She advocated for humane
treatment as well as safe and comfortable
environments for the patient. Through her
efforts, care was improved in the U.S.,
Canada, and Scotland.
 Nursing Education
 Eighteenth and Nineteenth Centuries
 In 1882, the McLean Asylum in Somerville,
Massachusetts, opened the first training
school in the world for mental health nurses.
 Edward Cowles, the physician
superintendent of McLean, believed that the
presence of a “nurse” indicated not only
that the patient was ill but also that there
was a hope of recovery.
 Other schools were opened:
 Bellevue Training School in New York
 Connecticut Training School in New Haven

These schools operated under the Nightingale model.

The year 1893 marked the first meeting of organized

nursing in the U. S.

Important Nurse Leaders included: Isabel Hampton and

Lavinia Dock.

Mental health nurses continued to be trained at asylums

and their training evolved to keep up with new
approaches in psychiatric care.
 Twentieth Century
 The American Psychiatric Association
established a committee on Training Schools
for Nurses.
 Johns Hopkins Hospital School included
psychiatric nursing in the training of general
nurses. This was the first time a hospital
program offered training in psychiatric care
to all students.
 By 1920, the first psychiatric nursing
textbook was publish, Nursing Mental
Disease by Harriet Bailey.
 In the 1930s, somatic therapies emerged
 In 1946, the U.S. Congress passed the
National Mental Health Act, which
established the National Institutes of Mental
Health.
Peplau and the Therapeutic
Relationship
 Peplau was the first nurse to identify
psychiatric nursing both as a
essential element of general nursing
and as a specialty area that
embraces specific governing
principles” (p. 24).
 She was the first nurse to describe
the nurse-patient relationship as
foundation of nursing practice (p.
24).
 She emphasizes the shifting the
focus from what nurses do to
patients to what nurses do with
patients.
 She described that stages of the
nurse-patient relationship (p. 24).
 The skills of the psychiatric nurse
include: observation, interpretation,
and intervention.
 She also applied Sullivan’s theory of
anxiety to nursing practice.
 Dorothea Orem
 Proposed a general self-care deficit
theory of nursing.
 Has three constitute theories –self-
care, self-care deficit, and nursing
systems which are based on six
central and one peripheral concept.
 Self-care
 Self-care agency
 Therapeutic self-care demand
 Self-care deficit
 Nursing agency
 Nursing system
 Focus: Goal of self-care as integral
to the practice of nursing (p. 25)
 She emphasized the role of the nurse
in promoting self-care activities of
the client; this has relevance to the
seriously and persistently mentally ill
client (p. 25).
 Jean Watson
 She first differentiated between
nursing and medicine by stating that
curing is the domain of medicine,
and caring is the domain of nursing.
 She proposed 10 carative factors
that involved forming a humanistic,
altruistic system of values: instilling
faith-hope; cultivating sensitivity to
one’s self and
To others; developing helping-trust
relationships; expressing positive
and negative feelings’ using scientific
problem-solving methods for decision
making; promoting interpersonal
teaching-learning; providing an
environment that supports, protects,
and corrects mental, physical,
sociocultural, and spiritual aspects;
Assisting with the gratification of
human needs; and allowing for
existential-phenomenological forces.

Source: Frisch, N. C., & Frisch, L. E.

(2006). Psychiatric mental health
nursing, 3rd ed. Australia: Thomson
Delmar Learning. (p. 30)
Neuroscience as a Basis for
Practice
 Mental phenomena are somehow
caused by an array of biochemical
and neurophysiological processes
that take place from moment to
moment.
 Psychotropic Drugs
 Pharmacological treatment of mental
disturbances is directed at the
suspected transmitter receptor
problem.
 Transmitters (p. 40)
 Dopamine
 Norepinephrine
 Serotonin
 Histamine
 GABA
 Glutamate
 Acetylcholine

 Substance P

 Somatostatin

 Neurotensin
What is psychiatric Mental
Health Nursing? (p. 64)
 Psychiatric nursing is “the diagnosis
and treatment of human responses
to actual or potential mental health
problems” (p. 64)
 Box 4-1: Psychiatric Mental Health
Nursing’s Phenomena of Concern (p.
64)
What do psychiatric Nurses
Do?
(p. 65)
 “to promote and maintain optimal
mental functioning, to prevent
mental illness (or further
dysfunction), and to help clients
regain or improve their coping
abilities” (p. 65)
 Psychiatric Mental Health
Nursing Interventions (p.
66)
Basic Level Nursing
 Counseling
 Milieu therapy
 Promotion of self-care activities
 Psychobiological interventions
 Health teaching
 Case management
 Health promotion and health
maintenance
Advanced Level Nursing
 All of the above plus
 Psychotherapy
 Medication prescription and treatment

 Consultation
 Where do psychiatric
nurses work? (p. 87)
 Primary Prevention
 Secondary Prevention
 Tertiary Prevention
 Cultural and Ethnic
Considerations
 Cultural is a complex whole,
including knowledge, belief, art,
moral, law, custom, and any other
capabilities and habits acquired by
man as a member of society.
 It comprises every verbal or
behavioral system that transmits
meaning.
 It is learned, shared, and ever-
changing.
 It is learned through socialization,
shared by all group members, and
associated with adaptation to the
environment.
 Cultural blindness is the attempt
to treat all person fairly by ignoring
differences and acting as though the
differences do not exist.
 Can be perceived as insensitivity just
as readily as are stereotyping and
ethnocentrism.
 Normal vs. Abnormal
Behavior
 What is normal in one culture may
not be normal in another.
 A Global Perspective
 Terms
 Minority (p. 100)
 Culture (p. 100)

 Ethnicity (p. 100)

 Worldview (p. 100; Table 7-2 on p. 102)

 Enculturation (p. 103)

 Understanding Culture in
the Context of Mental
Illness
 Table 7-3: Selected Nonverbal
Communication Patterns (p. 103)
 “Deviance from cultural expectations
is considered by others within the
culture to be a problem and
frequently is defined by the cultural
group as “illness” (p. 103)
 Legal and Ethical
Guidelines
 Terms (p. 116)
 Ethics
 Bioethics
 Five Principles of
Bioethics
 Beneficence
 Autonomy
 Justice
 Fidelity (nonmaleficence)
 Veraceity
 Guidelines
 Box 8-1: Code of Ethics for Nurses
(p. 117)
 Civil Rights
 Specific Client Rights
 Client Consent
 Communication

 Freedom from Harm

 Dignity and Respect

 Confidentiality
 Participation in Plan of Care
 Nursing Process
 Assessment (pp. 139 – 144)
 Diagnosis (p. 145)
 Outcomes (p. 146)
 Planning (pp. 146 – 148)
 Implementation (p. 148 – 149)
 Evaluation (p. 149)
 Documentation (p. 150)
 Goals of a Therapeutic
Relationship (p. 156)
 Facilitating communication
 Assisting
 Helping
 Promoting
 Factors that Enhance
Growth in Others (pp. 157 –
158)
 Genuineness
 Empathy
 Positive Regard
Establishing Boundaries
 Problem Areas
 Overhelping
 Controlling

 Narcissism
 Peplau’s Phases of Nurse-
Client Relationship (pp. 163
– 168)
 Orientation Phase
 Working Phase
 Termination Phase
Tools of Psychiatric Mental
Health Nursing
 Communication is the key to
successful psychiatric – mental
healthy nursing.
 Psychiatric mental health nurses use
tools of self and tools of knowledge
in their work.
 Therapeutic communication is the
purposeful use of dialog to bring
about the client’s insight, control of
symptoms, and/or healing.
 To accomplish therapeutic
communication, the nurse needs to
understanding communication theory
and how to build a positive nurse-
client relationship.
 Physical Space

 Denotes a sense of relationship

between two people.
 Has meaning in communication.
 Public space = approximately 12 feet
 Social space = 9 to 12 feet
 Personal space = 18 inches to about
4 feet
 Intimate space = closer than 18
inches
 Actions or Kinetics
 Refer to movements, expressions,
question, and posture that
accompany interactions and
influence communications.
 NOTE: They are almost always
culture-bound.
 Paralinguistic Cues
 Provide the context in which the
words are delivered, and they
influence meaning directly.
 Include tone, pitch, emotions
expressed verbally (such as anxiety
or anger or fear), sounds of
hesitation, nervous laughter, and
nervous coughing.
 Must be interpreted within the
context of the client’s cultural and
 Touch
 Is a form of communication used
almost daily by nurses providing
direct physical care and support to
clients.
 Can convey warmth, positive regard,
support during silence, and
reassurance that the nurse if fully
present and caring.
 Has many meanings (appropriate
and inappropriate touching).
 Verbal Communication
 Is the use of words, written and
spoken, to send messages to
another.
 For communication to be most
therapeutic, it must convey a
respectful attitude, one that supports
the individuality and self-esteem of
both the client and the nurse.
 Nonverbal
Communication
 Refers to all of the messages sent by
others than verbal or written.
 Includes behaviors, cues, and
presence (such as proximity) that
sends a message.
 Techniques that Enhance
Communication (p. 187-
188)
 Using Silence
 Accepting
 Giving Recognition
 Offering Self
 Offering General Leads
 Giving Broad Openings
 Placing the Events in Time or
Sequence
 Making Observations
 Encouraging Description of
Perception
 Encouraging Comparison
 Restating
 Reflecting
 Focusing
 Exploring
 Giving Information
 Seeking Clarification
 Presenting Reality
 Voicing Doubt
 Seeking Consensual Validation
 Verbalizing the Implied
 Encouraging Evaluation
 Attempting to Translate into Feelings
 Suggesting Collaboration
 Summarizing
 Encouraging Formulation of a Plan of
Action
Obstructive Communication

(pp. 191 – 192)

 Giving Premature Advice
 Minimizing Feelings
 Falsely Reassuring
 Showing Nonverbal Signs of Boredom
or Resentment
 Making Value Judgments
 Asking “why” question

63
 Asking Excessive Questions
 Giving Approval, Agreeing
 Disapproving, Disagreeing
 Changing the Subject
Levels of Psychiatric Mental
Health Clinical Nursing
Practice (p. 65)
 Basic Level
 Advanced Level
 Advanced practice RN – psychiatric
mental health (APRN-PMH)
 Levels of Anxiety
 Mild Anxiety (p. 213)
 Moderate Anxiety (p. 213)
 Severe Anxiety (p. 214)
 Panic Level of Anxiety (p. 215)
 Two Common Features of
Defense Mechanisms
 “They all (except suppression)
operate on an unconscious level, so
that we are not aware of their
operations” (p. 17).
 “They deny, falsify, or distort reality
to make it less threatening” (p. 17).
 Common Defense
Mechanisms
 Most Healthy Defenses (pp. 217-218)
 Altruism
 Sublimation

 Humor

 Suppression
 Intermediate Defenses (p. 218)
 Repression
 Displacement

 Reaction Formation

 Somatization
 Immature Defenses (pp. 218-220)
 Passive aggression
 Acting-Out Behaviors

 Dissociation

 Devaluation

 Idealization Splitting

 Projection

 Denial
 Regression
 Suppression
 Sublimation

(p. 95)