Principles and Practice of Psychiatric Nursing TP Prema, KF Graicy
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Review of Psychiatric NursingCHAPTER 1

Nursing or caring the sick is an art in itself. It is a need-based art, which inherited not only to human beings but to animal kingdom also. Often we see an animal in need is helped or nursed by another, it is fed, carried and even protected.
In early human history family members, servants, friends, neighbours and some religious groups carried out the nursing or caring the sick. Later these activities were carried out by women for their livelihood, till the middle of 18th century. Around this time the scientific knowledge was gradually added to this nursing art.
Florence Nightingale, who is known as the mother of modern nursing formulated the scientific reasons for the nursing work. She discussed about disease conditions, causes, causative organisms, route of entry of microorganisms into human body and also the importance of environmental hygiene in the maintenance of health. She also told that nurse could cause infections to the patients if she does not practice aseptic techniques while she does wound dressing and other procedures. The nursing could be defined as an art and science, 2when the original art is combined with scientific knowledge and reasoning.
At different periods of history, different scholars viewed nursing, in their own words. Some of them are mentioned here. The unique function of nurse is to assist the individuals, those activities contributing health or its recovery or to a peaceful death, that she would perform unaided if she had strength, will or knowledge to help the patient to gain independence as rapidly as possible (Henderson, 1966) Watson states Nursing is a service of caring (1979). The type of nurse required today is one who possesses an all-around personality, the required general education and prescribed professional education. She should have a desired degree of maturity with possibility of development to enable her to work effectively with in the community. She should be competent enough to share professional responsibility as a member of health team in treating the sick (Government of India, 1989).
The present day nurse is an encounter with a client and his/her family, wherein the nurse observes, supports, communicates, ministers and teaches. She also contributes to the maintenance of optimum health and provides care during illness until the client is able to assume responsibility for the fulfillment of his own basic needs. In other words the nurse has the responsibility not only in the hospital, but also to take care of the client to get rehabilitated to his maximum functional ability within the limits of the prognosis of disease he is affected.
Because of the different views of different leaders, in the last two centuries nursing is gone through several changes. These changes happened due to changes in nursing curriculum, medical practices, economy of 3developed and developing countries, in the political scenario and the facilities available to treat and rehabilitate the patients. In the nursing education and practice, important points to remember are the courses available in different specialities like diplomas in critical care nursing, operation theater nursing, oncology nursing, neuroscience nursing. Nursing for psychiatric patients also turned into speciality nursing for the last few decades. Psychiatric nursing underwent many evolutions before it turned into a speciality nursing. Few important leaders and their contributions to psychiatric nursing are discussed below.
Linda Richard who graduated in 1873 from New England Hospital developed better nursing care in psychiatric hospitals and organized educational program in the state Mental Hospital of England. For this reason she is known as the first psychiatric nurse. During her times in Malian Hospital (WAVERLY), the first school of nursing opened to prepare nurses to care for mentally ill. The importance of Linda's program was, it prepared the nurses to assess both physical and emotional needs of patients.
In 1913, John Hopkins was the first school of nursing to include a fully developed course curriculum to prepare the psychiatric nurse.
Along with the prescribed curriculum nursing leaders started defining the psychiatric nursing and listed down some unique functions of psychiatric nurse, Stockwell (1985) defined psychiatric nursing as a complex, skilled planned activity that aim the teamwork and co-operation at restoring full health functioning of mentally ill individuals, minimizing the defect or disabilities arising form gross illness or institutional care, protecting the individual from harming himself or others.4
Peplau (1952) in her book “Interpersonal Relation in Nursing” described the skills, activities and role of the psychiatric nurse. She believed the four phases of interpersonal relationship (orientation, identification, exploration and resolution) should be practiced by the psychiatric nurse, while taking care of her clients. In 1953, National League for Nurses (America)' published a study of desirable functions and qualifications for psychiatric nurse.
This report identified the following desirable functions for psychiatric nurse:
  1. Collecting the significant data relating to identification of problem in observing the behavior of patient and recording them.
  2. Making inferences and judgment based on these data and leading to action, i.e. interpreting the behavior of the patient.
  3. Acting and intervening on the basis of inferences.
  4. Evaluating the entire process in terms of whether problems are solved.
By 1960, the services of the psychiatric nurse is extended to different areas other than inpatient settings. The extended areas are outpatient department, partial hospitalization, community services, emergency services, consultations and even teaching. She is included in the health team of doctors, clinical psychologist, psychiatric social workers, occupational therapist, etc. If one looks at the evolution in psychiatry one can equate the changes happened in the psychiatric nursing also especially in 20th century.
Till Philippe Pinal broke the chains of psychiatric patients in 1792, they were given only institutional care in lunatic asylums. During that period nurse also was assigned to do the minimum basic needs for these individuals and the last rites after death.5
Fraud the Father of Psychology established that the fixation theory at different stages (Oral, anal, phallic) in childhood, make the individual to behave abnormally sometimes or the other in their lifetime. He practiced behavioral therapies to modify the abnormal behavior of the individuals. During this period nurses were given the responsibility of observing and reporting of patient's behavior and even to become co-therapist in these modes of behavioral modification.
Social science formulated that society is all cause of behavioral deviation in the individuals and society to be guided to help the individuals to correct the behavior. In this period nurses were asked to take up the responsibility of involving family members and society in treating and preventing the behavioral problems.
Psychiatrists started physical therapy in the treatment of their clients. Two main physical therapies were insulin coma therapy and the modified electroconvulsive therapy. After the insulin administration the patient slips into deep coma where the nurses were assigned to observe the vital signs and report if necessary. It happened while the patient is treated with unmodified electroconvulsive therapy also.
In 1950's, the psychotropic drugs entered in the psychiatic practices and nurses' role also changed accordingly. Here the nurse is supposed to know the chemical combination of the drug, routes of administration, dosage, indications, contraindications, side effects and nurses responsibilities when these drugs are administered.
The increasing number of individuals with behavioral problems in the world is great and alarming. The non-availability of enough hospital beds is a considerable problem of many countries. The policy makers in different 6countries shifted the focus of treating of these individuals from inpatient setup to out patient or to the community. National Mental Health Program (NMHP) was formulated and the community approach of psychiatry patients in practice. Accordingly, nurses' role also changed shifting from in patient setup to community. Therefore, she is involved at three levels of prevention, i.e. primary prevention, secondary prevention and tertiary prevention. In this context, Clifford Beers to be remembered. Having spent several years in mental hospital he wrote a book called “A Mind that Found Itself” in 1907. He emphasized on prevention and early recognition of behavioral changes.
Maxwell Jones demonstrated the practice of Milieu therapy and therapeutic community. Psychiatric nurses act as a team member in the procedure of Milieu therapy and therapeutic community.
There is one commendable development in psychiatric nursing itself without related to changes in psychiatric practice that is nothing but nursing process. The nursing process is an interactive problem solving process, a systematic and individualized way to fulfill the goal of nursing care. The nursing process acknowledges the autonomy of the individual and his freedom to make decisions and be involved in his own care. It is done in different interrelated phases.
Phases of Nursing process are:
  1. Data collection.
  2. Formulation of nursing diagnosis.
  3. Planning the nursing care.
  4. Implementation of nursing interventions.
  5. Evaluation.
Practicing the nursing process is a definite forward step in nursing which make the nurse independent in her professional career.7
To conclude the nursing started as a need based art. But developed tremendously with the help of the contributions from nursing leaders, enormous changes happened in medical practice, economy of different countries, policies of governmental and non governmental organizations and even the changes in bio and information technologies. It is not a simple art now. One should have required general education and prescribed professional education before she becomes a qualified nurse. To become psychiatric nurse she has to undergo a special training program by which she is able to perform the prescribed functions to look after the individuals in behavioral problems.
There are special courses conducted in different parts of the world to train the persons to become psychiatric nurse.
In India we have diploma courses conducted in:
  1. NIMHANS Bangalore.
  2. Raveli Ranchi.
  3. Assam.
Postgraduate programs are available in:
  1. NIMHANS Bangalore.
  2. Chandigarh.
Around 1000 nurses have undergone DPN in NIMHANS and 30 nurses had postgraduation courses in NIMHANS (MSc).
In India, individuals with behavioral problems were admitted in the hospitals to avoid homicide in community. These indoors had only healthy, hefty male individuals to control their manic behavior.
Asylums were built here and there in India where nurses were given the responsibility of giving minimum 8physical care when they are alive and last rites after death.
In 1950s, trends in psychiatric care changed due to the drugs available in the practice of psychiatry and also other physical therapies made the nursing leaders to include some chapters in psychiatric nursing in nursing curriculum. The curriculum developed in 1986 by INC included a good amount of theory classes with practicals in nursing to care the individuals with behavioral problems. But in 1960, Normayil in Lucknow started the nursing training. Around this time, a training in psychiatric nursing started for 10 weeks, Later it is increased to 6 months.
In 1956, NIMHANS also started a program namely Diploma in Psychiatric Nursing (DPN) with maximum of 15 seats. It was discontinued for few years. But restarted in 1975 as a program for 11 months. Now it continues as a course for full academic years.
In 1975, RAK College of Nursing Delhi started postgraduation in psychiatric nursing. Later other colleges in the country like PGI Chandigarh, SNDT Bombay, CMC Vellore and NIMHANS also started Postgraduation in Psychiatric nursing.
At present 15 colleges give postgraduation in psychiatric nursing maximum of 60 seats.
DPN is offered in 3 institution with a maximum of 50 candidates.
Current Trends
Now, any medical or Paramedical course curriculum includes minimum exposure to psychiatry. Any branch of medicine and nursing concentrate on holistic approach. So, there is no question that psychiatric nursing is a speciality within nursing. All modern nursing theorems 9address the holistic nature of people and emphasize the need to care for a person's body and mind together. Now, the psychiatric nurse should keep her identity doing a better role. She can work at two levels. One, the nurse works with individual's families, communities and groups to promote health including mental health, assess dysfunction, assist clients to regain coping and prevent further disability. In the second level, the nurse can focus on full range of activities from mental health promotion to illness care, with additional skills in the diagnosis and treatment of mental disorders.
In addition to these levels of practice there are also clear subspecialities available by virtues of education or long-term experience. A few available subspecialities are child psychiatry, adolescent psychiatry, adult psychiatry, geriatric psychiatry, psychiatry for deaddiction and for depression and for chronically mentally ill. These categories are not virtually exclusive but they provide a means of identifying the nurses' specialization.
Future Directions
Psychiatric branch of medicine is moving towards biological, genetic and pharmacological era. These advances hold great promise for treatment. They have also raised concerns that advancing medical treatment could minimize the recognition of the continued need for psychotherapeutic interventions. So there is an urgent need for nurses with psychiatric nursing skills to provide service to individuals with acute and chronic illness terminal diagnosis, problem associated with ageing, grief, AIDS and other serious illness or stressful events.
Many believe that the major challenge for psychiatric nursing in the 21st century is keeping the nursing in 10par with the changes happening due to the new discoveries of science, genetics and technology. Psychiatric nursing must include neuroscience as well as behavioral sciences. The future provides challenging work for those interested in combining knowledge of neuroscience with an understanding of human behavior and their relationship to social and environmental conditions, affecting people.
Today many persons may be underdiagnosed and untreated. Those who are severely ill may be hospitalized for a limited period and get discharged with medication. So, there is an increased need for psychiatric specialists in home care. At the same time the motion of prevention is not being fully realized and practiced in most aspects of health. Mental health is not an exception to it.
So, it is important to have program to promote healthy parenting, stress reduction, avoidance of addictive substances in many communities, at large in all over the world. Contemporary issues such as domestic violence, addiction, homelessness, poverty where psychiatric care cannot remedy individual's problems, without solving or preventing larger social issue.
As the majority of nursing care moves from hospital to community there will be an increasing need for psychiatric nurses to use all of their creativities and skills to provide needed services in most effective way possible in community.
Closing down the hospitals, the government is looking for more and more homes for psychiatric patients. Nurses have many responsibilities in homes for these patients along with the home care responsibilities. Psychiatric nurses have to be closely vigilant to the changes happening around and prepare herself to meet the newer roles time to time.