Mental Health and Mental Illness

 Mental Health
o State of well-being
o Able to recognize own potential
o Cope with normal stress
o Work productively
o Make a contribution to community
o Ability to
 Think rationally
 Communicate appropriately
 Learn
 Grow emotionally
 Be resilient
 Have a healthy self-esteem
 Realistic goals and reasonable function within the individual’s role
 Mental Illness
o Disorders with a definable diagnosis
 DSM-5
o Culturally defined
o Significant dysfunction in mental functioning
o Causes
 Developmental
 Intellectual disability
 Autism
 Biological
 Prenatal exposure to alcohol
 Oxygen deprivation at birth
 Psychological Disturbances
 Bipolar disorders
 Schizophrenia
o Continuum
 Everyone falls somewhere on the spectrum
 Sections
 Well-Being
 Emotional Problems or Concerns
o Temporary
o Mild-to-moderate distress
o Minor or temporary impairment
 Mental Illness
o Chronic
o Marked distress
o Moderate-to-disabling or chronic impairment
o Causes serious dysfunction in daily life
 Recovery
o Process of change
o Improvement of health and wellbeing
 o Living a self-directed life
o Striving to reach full potential
 Influencing Factors
o Individual
 Management of thoughts and feelings
 Ability to navigate life
 Management of everyday stress and pressures
 Responses to social cues
 Participation in social activities
 Resilience
 Ability and capacity to secure resources needed to support
wellbeing
 Characterized by
o Optimism
o Sense of mastery
o Competence
 Essential to recovery
 Resilient people are effective are regulating their emotions and not
falling victim to negative thoughts
o Social and Economic Circumstances
 Family
 Can promote confidence and coping skills
 Can instill anxiety and feelings of inadequacy
 School and Peer Groups
 Socioeconomic Status
 Dictates access to resources
 Basic needs
 Educational advancement
o Environmental Factors
 Policies
 Insurance
o Mental health coverage is slim
o Low reimbursement
 Healthcare Systems
 Lack of Mental Health Resources and Providers
 Culture
 Ex. Scientology denies mental illness
 Diathesis-Stress Model
o Most accepted explanation for mental illness
o Diathesis
 Biological predisposition
o Stress
 Environmental stress or trauma
o Combination of genetic vulnerability and negative environmental stressors
o Most psychiatric disorders result from a combination of genetic vulnerability and
negative environmental stressors
  DSM-5
o Official medical guidelines of the APA for diagnostic psychiatric disorders
o Identifies disorders based on specific criteria
 Influenced by multi-professional clinical field trials
 Psychiatric Mental Health Nurses
o Promote mental health through assessment, diagnosis, and treatment of behavioral
and mental disorders
o Assist people in crisis, those experiencing life problems, and those with long-term
mental illness
o Work with people throughout the lifespan
o Employed in a variety of settings and among varied populations
o Levels of Practice
 Basic
 Psychiatric Mental Health RN (PMH-RN)
 2 years full-time work, 2000 clinical hours, 30 hours CE, and a
certification exam for the BC title
 Advanced Practice
 Psychiatric Mental Health Advanced Practice RN (PMH-APRN)
 Requires a MSN or DNP

Treatment Settings
 Outpatient Care
o Primary Care Providers
 Often the first point of contact
 Treat uncomplicated psychiatric problems
 Mild depression
 Anxiety
 Sleep problems
 Most people do not venture beyond this level of care
 More comfortable
 Familiar setting
 Decreased stigma
 Disadvantages
 Time constraints
o 15-minute appointments are inadequate for a mental health
assessment
 Limited training in psychiatry
 Lack of expertise in diagnosis and treatment of psychiatric
disorders
o Oftentimes refer patients to specialty mental health care
o Specialized Psychiatric Care Providers
 Educational background and experience in psychiatric problems and
mental health
 Types of Providers
 Psychiatrists
 o Can diagnose and prescribe medicine
 PMH-NP
o Can diagnose and prescribe medicine
 Psychologists
 Social Workers
 Counselors and Therapists
 All providers are educated to use psychotherapy (talk therapy) and lead
group therapy
 Many providers have sub-specialties
 PTSD
 Child and Adolescent Care
 Homeless Care
o Patient-Centered Health/Medical Homes
 Provides access to physical, behavioral, and community health, as well as
social services
 Comprehensive care
 All levels (preventative, acute, and chronic) of mental and physical
care are addressed
 Developed in response to fragmented care
o Community Health Centers
 Federally funded
 Provide mental health care to those who can’t afford it
 Free or low-cost slide scale
 Utilize multidisciplinary teams
 Services
 Patient intake
 Medication management and administration
 Psychotherapy
 Case management
o Psychiatric Home Care
 Community-based treatment model
 Requirements per Medicare
 Homebound status
 Presence of psychiatric diagnosis
 Need for skills of PMH-RN
 Plan of care ordered by MP/PMH-NP
 Medicare allows for 2 types of health care providers
 MSW
o Provide counseling
o Link patients with services
 PMH-RN
o Provide evaluation, therapy, and teaching
o Visit patient 1-3 times weekly
 Limited time period
  Allows nurse to address access to services and
adherence with treatment
 Must assess agitation and potential for violence
o Assertive Community Treatment
 Intensive type of case management
 Developed for severely mentally ill patients who would not participate in
traditional forms of treatment
 Meeting the patient in their homes, agencies, clinics, etc.
 Attempting to prevent unnecessary and expensive repeat
hospitalizations and ED use
 Multidisciplinary team
 RN is usually the case manager
 Visits patients 3-5 times weekly
 Supervised by MD/PMH-NP
o Intensive Outpatient Programs/Partial Hospitalization
 Held M-F for 4-6 hours
 Include medication management, therapy, and nursing intervention
o Other
 Telephone Crisis Counseling
 Telephone Outreach
 Internet
 Telepsychiatry
o Role of the Nurse
 Strong problem-solving and clinical skills
 Cultural competence
 Flexibility
 Knowledge of community resources
 Autonomy
 Promoting recovery and continuation of treatment
 Emergency Care
o Primary Goals
 Triage
 Determining the severity of the problem and the urgency of a
response
 Stabilization
 Resolution of the immediate crisis
o Often provides a bridge from the community to more intensive psychiatric
services
 Inpatient care
 Inpatient Care
o Reserved for those who are suicidal, homicidal, or extremely disabled
 The top five diagnoses for inpatient patients are mood disorders, substance
use disorders, neurocognitive disorders, anxiety disorders, and
schizophrenia
o Settings
 Crisis Stabilization/Observation Units
  Rapid stabilization and short-length stay
 General and Private Hospitals
 State Hospitals
 Serve the most severely ill patients
 Uninsured patients
o Entry to Inpatient Care
 Direct admission on referral
 Emergency department or crisis service
 Voluntary
 Involuntary
o Patients’ Rights
 Hospitalized patients retain their rights as citizens
 Patients’ need for safety must be balanced against their rights as citizens
 Mental health facilities have written statements of patient rights and
applicable state laws
o Teamwork and Collaboration
 Treatment Team
 Team of professionals and staff who work together to provide care
o Includes the patient
o Provider, MSW, RN, PharmD, etc.
 Meet 1-2 times weekly
 Nurse leads the meetings
o Only discipline that is represented on the unit at all times
o Contributes valuable information
 Continuous assessments
 Patient’s adjustment to the unit
 Health concerns
 Psychoeducational needs
 Deficits in self-care
 Treatment plan provides a guideline for the patient’s care during their stay
 Based on goals for hospitalization
 Defines how goals will be measured
 Members of each discipline are responsible for gathering data and
participating in the plan of care
o Therapeutic Milieu
 Surroundings and physical environment
 Patients
 Staff
 Structure
o Activities
o Rules
o Reality orientation practices
o Environment
 Emotional climate
 Well-managed milieu offers patients a sense of security and promotes
healing
  Managing crises
 Behavioral crises can lead to patient violence
 Staff practice crisis prevention and management techniques
 Special teams that respond to psychiatric emergencies practice
crisis management
 Seclusion, restraint, and emergency medication are actions of last
resort
 Safety
 Safe environment is essential to any inpatient setting
 Staff members check all personal property and clothing for
potentially harmful items prior to taking the patient on the unit
 Staff track patients’ whereabouts
 Staff monitor visitation
o Nursing Role
 Complete comprehensive data collection
 Includes patient, family, and other health care workers
 Develop, implement, and evaluate plans of care
 Assist or supervise workers
 Maintain a safe and therapeutic environment
 Facilitate health promotion through teaching
 Monitor behavior, affect, and mood
 Maintain oversight of restraint and seclusion
 Coordinate care with the treatment team
o Specialty Settings
 Pediatrics
 Geriatrics
 Veterans
 Forensics
 Alcohol and Drug Abuse
 Self-Help
 Prevention Strategies
o Primary
 Occurs before any problem manifests
 Aim is teaching coping strategies and providing psychosocial support
o Secondary
 Aim is to reduce the prevalence of psychiatric disorders
 Aim is early identification, screening, and prompt treatment
o Tertiary
 Treatment of disease
 Aim is to prevent progression to a severe state, disability, or death

Cultural Implications
 World Views
o Scientific frameworks that guide nursing and psychological theories, as well as
the understanding of mental health and illness
o Based on Western cultural ideals, beliefs, and values
 o Nurses should consider how a patient’s culture and/or belief system might affect
their nursing care
o Western Tradition
 Identity found in individuality
 Values
 Autonomy
 Independence
 Self-reliance
 Mind and body are separate entities
 Disease has a cause, and treatment is aimed at eradicating that cause
o Eastern Tradition
 Family is the basis for identity
 Family interdependence
 Group decision-making
 Body-mind-spirit is one entity
 No separation between a physical and psychological illness
 Disease is caused by fluctuations in opposing forces
 Ex. Yin-yang energies
 People are born into an unchangeable fate
 One must simply comply
o Indigenous Tradition
 Places significance on the place of humans in the natural world
 Basis of identity is that of the tribe
 Person is an entity only in relation to others
 Disease is caused by a lack of harmony between the individual and the
environment
 Impact of Culture on Mental Health
o Each culture has different patterns of nonverbal communication
o Each culture follows different rules of etiquette
o Beliefs and values
 Their culture defines what is within the range of normal and what is
outside that range
 Culture defines normality and mental health
o Nurses should strive to be sensitive to one’s culture and belief system
 Avoid ethnocentrism
 Believing your way of thinking and behaving is the only correct
and natural way
 Cultural Barriers to Quality Mental Services
o Communication barriers
 Language differences
o Stigma of mental illness
o Misdiagnosis
o Cultural concepts of distress
 At-Risk Populations
o Immigrants
o Refugees
 o Cultural “minorities”
 Cultural Competence
o 5 Constructs
 Cultural Awareness
 Recognizes the enormous impact culture makes on patients’ health
values and practices
 Examine beliefs, values, and practices of own culture
 Understands that EBP guidelines may NOT be applicable to all
people
o Derived from studies involving people primarily of
European descent
 Recognize that during a cultural encounter, three cultures are
intersecting
o Culture of patient
o Culture of nurse
o Culture of setting
 Cultural Knowledge
 Learn by attending cultural events and programs
 Forge friendships with diverse cultural groups
 Learn by studying and/or asking questions
 Learning cultural differences helps the nurse
o Establish rapport
o Understand behaviors and avoid misunderstandings
o Ask culturally relevant questions
o Identify cultural variables to be considered
 Cultural Encounters
 Deter nurses from stereotyping
o Can NOT assume that every member of a group is like all
other members
 Help nurses gain confidence in cross-cultural interactions
 Help nurses avoid or reduce cultural pain
o Occurs when nurses cause the patient discomfort or offense
by a failure to be sensitive to cultural norms
o If you do offend someone, take measures to recover trust
and rapport by apologizing and expressing willingness to
learn from the patient
 Cultural Skill
 Ability to perform a cultural assessment in a sensitive way
o Use professional medical interpreters to ensure meaningful
communication
o Use culturally sensitive assessment tools
 Goal
o A mutually agreeable therapeutic plan
 Culturally acceptable
 Capable of producing positive outcomes
 Cultural Desire
  Genuine concern for patient’s welfare
 Willingness to listen and understand a patient’s viewpoint
 Nurses exhibit cultural desire through patience, consideration, and
empathy
 DO NOT behave like you know what is best for the patient
 DO NOT impose the “correct” treatment on the patient
 Inspires openness to meet the patient’s cultural needs

Legal and Ethical Considerations

 Ethical Concepts
o Ethics
 The study of philosophical beliefs about what is considered right or wrong
in a society
o Bioethics
 Used in relation to ethical dilemmas surrounding health care
 5 Principles
 Beneficence
o The duty to promote good
 Autonomy
o Respecting the rights of others to make their own decisions
 Justice
o Distribute resources and care equally
 Fidelity
o Nonmaleficence
o Maintaining loyalty and commitment
o Doing no wrong to a patient
 Veracity
o One’s duty to always communicate truthfully
o Ethical Dilemma
 Conflict between two or more courses of action, each with favorable and
unfavorable consequences
 Mental Health Laws
o Admission Procedures
 Voluntary Admission
 Sought by a patient or guardian
 Can request leave
o Treatment team decides whether to let the patient go or to
involuntarily commit them
 Involuntary Commitment
 Without patient’s consent
 Often court-ordered
 Patient must be mentally ill, a danger to self or others, and/or
unable to acquire basic necessities
 Types
o Emergency Commitment
 Temporary admission
Person is confused or demented, requiring an
emergency admission
 Used for observation, diagnosis, and treatment
 Generally lasts 24-96 hours
 Court hearing before discharge or next admission
o Assisted Outpatient Treatment
 Court-ordered
o Patients’ Rights
 Right to treatment
 Right to refuse treatment
 Right to informed consent
 Indicates that the patient has been provided with basic
understanding of risks, benefits, and alternatives
 Person must voluntarily accept treatment
 To be effective legally, it must be informed and in general a
physician or APRN must obtain the consent
 Rights regarding restraint and seclusion
 Must be used as a last resort
 Must be used in the least restrictive manner for the shortest period
of time
 Limits on orders
o Limited to 4 hours for adults
o Limited to 2 hours for 9-17 year-olds
o Limited to 1 hour for those under 9 years
o NO standing or PRN orders may be used
o A new order is needed for every time the patient is put in
restraints (even if it falls within the time limits of an old
order)
 Nurse can put a patient in restraints, then get physician order in an
emergency
 Right to confidentiality
 Legal considerations
o HIPAA
o Confidentiality after death
o Confidentiality of professional communications
 Exceptions
o Duty to warn and protect third parties
 Falls on the provider or therapist
 If the patient threatens someone, the provider must
warn that person
 RN must tell the provider
o Child and elder abuse
 RN required to report any suspected abuse
 Protect your patients
o Tort Law
  Tort
 Civil wrong for which money damages may be collected by the
injured party (plaintiff) from the responsible party (the defendant)
 Intentional
o Willful or intentional acts that violate another person’s
rights or property
 Assault
 Threat of violence
 Battery
 Violence
 False imprisonment
 Invasion of privacy
 Unintentional
o Unintended acts against another that produce injury or
harm
 Negligence
 5 elements required to prove it
o Duty
o Breach of duty
o Cause in fact
o Proximate cause
o Damages
 Malpractice
o Documentation of Care
 A record’s usefulness is determined by evaluating (when the record is later
read) how accurately and completely it portrays the patient’s behavioral
status at the time it was written
 Medical Records
 Used for quality improvement
 Used as evidence
 Growing use of electronic documentation
o Violence
 Employers are not typically responsible for employee injury from violent
patients
 Always document the patient’s potential for violence
 Communicate observations to colleagues

Therapeutic Relationships
 Concepts of the Nurse-Patient Relationship
o Basis of all psychiatric nursing treatment approaches
o To establish that the nurse is
 Safe
 Confidential
 Reliable
 Consistent
o Relationship with clear boundaries
 Goals and Functions
o Facilitates communication of distressing thoughts and feelings
o Assist patient with problem solving
o Help patient examine self-defeating behaviors and test alternatives
o Promote self-care and independence
o Provide education
o Promote recovery
 Social Relationships
o Initiated for the purpose of friendship, socialization, enjoyment, or
accomplishment of a task
o Mutual needs are met
o Communication to give advice, give, or ask for help
o Content of communication is superficial
 Therapeutic Relationships
o Needs of patient are identified and explored
o Clear boundaries are established
o Problem-solving approaches are taken
o New coping skills are developed
o Behavioral change is encouraged
 Necessary Behaviors for Nurses
o Accountability
o Focus on patient’s needs
o Clinical competence
o Delaying judgement
o Supervision
 Boundaries
o Establishment
 Social
 Physical
 Psychological
o Blurring
 When the relationships slips into a social context
 When the nurse’s needs are met at the expense of the patient’s needs
 Transference
 Patient unconsciously and inappropriately displaces onto the nurse
feelings and behaviors related to significant figures in the patient’s
past
 Intensified in relationships of authority
 May be positive or negative
 Countertransference
 Nurse displaces feelings related to people in the nurse’s past onto
the patient
 Patient’s transference to the nurse often results in
countertransference in the nurse
 Common sign of countertransference in the nurse is
overidentification with the patient
  Values, Beliefs, and Self-Awareness
o Nurse’s values and beliefs
 Reflect own culture or subculture
 Derived from a range of choices
 Chosen from a variety of influences and role models
o Must respect patients’ values and reliefs
 Peplau’s Model of the Nurse-Patient Relationship
o Preorientation Phase
 Preparing yourself for your assignment
 Viewing the chart
 Researching the patient’s illness
 Discussing the patient’s case with staff
 Recognizing one’s own thoughts and feelings
o Orientation Phase
 Introduction
 Establishing rapport
 Parameters of the relationship are set
 Confidentiality is discussed
o Working Phase
 Maintain relationship
 Gather further data
 Explore problem areas in the patient’s life
 Patient education
 Promote patient’s
 Problem-solving skills
 Self-esteem
 Use of language
 Evaluate progress
o Termination Phase
 Final phase
 Summarize goals and objectives achieved
 Discuss ways for the patient to incorporate new coping strategies
 Factors that Promote Patient Growth
o Genuineness
o Empathy
 NOT sympathy
o Positive Regard
 Actions
 Attending
 Suspending value judgements
 Helping patients develop resources
 Attitudes

Therapeutic Communication
 Factors that Affect Communication
o Personal Factors
 o Environmental Factors
o Relationship Factors
 Verbal Communication
o All the words a person speaks
o Communicates
 Values and beliefs
 Perceptions and meaning
o Can convey
 Interest and understanding
 Insult and judgement
 Clear or conflicting messages
 Honest or distorted feelings
 Nonverbal Communication
o Tone of voice
o Emphasis on certain words
o Physical appearance
o Facial expressions
o Body language/posture
o Amount of eye contact
o Hand gestures
 Interaction of Verbal and Nonverbal Communication
o Messages can appear to be one thing when they are, in fact, another
o People are often less aware of their nonverbal messages and behaviors
o Effective communicators pay attention to both verbal and nonverbal cues
o Double-Bind Messages
 A contradictory message
 The recipient of the message is caught inside a contradictory statement in
which they cannot win
 Therapeutic Communication Techniques
o Tools for enhancing communication
o Using Silence
o Active Listening
o Clarifying Techniques
 Paraphrasing
 Restating
 Reflecting
 Exploring
 Open-ended questions
 Closed-ended questions
 Projective questions
 The “Miracle” question
o Attending Behaviors
 Eye contact
 Body language
 Proxemics
 The study of personal space
  US Standards
o Intimate Distance
 0-18 inches
o Personal Distance
 18-40 inches
o Social Distance
 4-12 feet
o Public Distance
 12+ feet
 Vocal quality
 Nontherapeutic Communication Techniques
o Excessive questioning
o Giving approval or disapproval
o Giving advice
o Asking “why” questions
o Arguing, minimizing, or challenging the patient
o Giving false reassurance
o Interpreting or speculating
o Probing into sensitive areas the patient doesn’t want to discuss
o Trying to “sell” the patient on accepting treatment
o Joining in attacks patients launch on others
o Participation in criticizing other staff members
 Preparing for the Clinical Patient Interview
o Pace
o Setting
 Quiet room
 Sense of security is important
o Seating
 Be sure to sit at eye level
 Always be between the patient and the door
o Introductions
 AIDET
 Confidentiality
o Initiating the interview

The Nursing Process and Standards of Care

 Assessment
o Age Considerations
 Children
 Majority of information comes from the parents or caregivers
 If you suspect abuse, interview the parent and child separately
 Adolescents
 Concerned with privacy
 Vulnerable Adults
 Anyone that is a legal adult but has a guardian related to their
inability to care for self
  Address the patient first
o This gives them a sense of dignity
 Older Adults
 Do not underestimate them
o HEADSSS
 Home environment
 Education and employment
 Activities
 Drugs, alcohol, or tobacco use
 Sexuality
 Suicide risk
 Safety
o Gathering Data
 Much can be gathered through simple observation
 ROS done by the provider
 To rule out medical issues
 Labs
 CBC
 CMP
 Thyroid function tests
 Mental status exam
 Brief psychiatric assessment
 Psychosocial assessment
 Spiritual/religious assessment
 Cultural and social assessment
 Validate the assessment
 Talk with the family or spouse
 Allows for more data collection
 Using rating scales
 Often used by providers
 Diagnosis
o Concepts
 Safety
 Psychosis
 Coping
 Communication
 Health Promotion
 Outcomes Identification
o Outcomes that reflect the maximal level of patient health and can be realistically
achieved through nursing interventions
 Planning
o Principles to consider
 Safe
 Compatible and appropriate
 Realistic and individualized
 Evidence-based
 Implementation
o Basic interventions
 Coordination of care
 Health education and promotion
 Milieu therapy
 Pharmacological, biological, and integrative therapies
 Evaluation
o Ongoing assessment
o Criteria-based