It is a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a co-existence between the realities of the self and that of other people and the environment.
Karl Menninger (1947) defines mental health as “An adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness”.
The American Psychiatric Association (APA 1980) defines mental health as “Simultaneous success at working, loving and creating with the capacity for mature and flexible resolution of conflicts between instincts, conscience, important other people and reality”.
Thus mental health would include not only the absence of diagnostic labels such as schizophrenia and obsessive compulsive disorder, but also the ability to cope with the stressors of daily living, freedom from anxieties and generally a positive outlook towards life's vicissitudes and to cope with those.
Components of Mental Health
The components of mental health include:
- The ability to accept self: A mentally healthy individual feels comfortable about himself. He feels reasonably secure and adequately accepts his shortcomings. In other words, he has self-respect.
- The capacity to feel right towards others: An individual who enjoys good mental health is able to be sincerely interested in other's welfare. He has friendships that are satisfying and lasting. He is able to feel a part of a group without being submerged by it. He takes responsibility for his neighbors and his fellow members.
- The ability to fulfill life's tasks: A mentally healthy person is able to think for himself, set reasonable goals and take his own decision. He does something about the problems as they arise. He shoulders his daily responsibilities, and is not bowled over by his own emotions of fear, anger, love or guilt (Box 1.1).
Indicators of Mental Health
Jahoda (1958) has identified six indicators of mental health which include:
- A positive attitude towards self: This includes an objective view of self, including knowledge and acceptance of strengths and limitations. The individual feels a strong sense of personal identity and security within the environment.
- Integration: Integration includes the ability to adaptively respond to the environment and the development of a philosophy of life, both of which help the individual maintain anxiety at a manageable level in response to stressful situations.
- Autonomy: It refers to the individual's ability to perform in an independent self-directed manner; the individual makes choices and accepts responsibility for the outcomes.
- Perception of reality: This includes perception of the environment without distortion, as well as the capacity for empathy and social sensitivity—a respect and concern for the wants and needs of others.
- Environmental mastery: This indicator suggests that the individual has achieved a satisfactory role within the group, society or environment. He is able to love and accept the love of others.
Characteristics of a Mentally Healthy Person
- He has an ability to make adjustments.
- He has a sense of personal worth, feels worthwhile and important.
- He solves his problems largely by his own effort and makes his own decisions.
- He has a sense of personal security and feels secure in a group, shows understanding of other people's problems and motives.
- He has a sense of responsibility.
- He can give and accept love.
- He lives in a world of reality rather than fantasy.
- He shows emotional maturity in his behavior, and develops a capacity to tolerate frustration and disappointments in his daily life.
- He has developed a philosophy of life that gives meaning and purpose to his daily activities.
- He has a variety of interests and generally lives a well-balanced life of work, rest and recreation.
Mental illness is maladjustment in living. It produces a disharmony in the person's ability to meet human needs comfortably or effectively and function within a culture.
A mentally ill person loses his ability to respond according to the expectations he has for himself and the demands that society has for him.
In general an individual may be considered to be mentally ill if:
- The person's behavior is causing distress and suffering to self and/or others.
- The person's behavior is causing disturbance in his day-to-day activities, job and inter personal relationships.
Mental and behavioral disorders are understood as clinically significant conditions characterized by alterations in thinking, mood (emotions) or behavior associated with personal distress and/or impaired functioning (WHO, 2001).
Characteristics of Mental Illness
- Changes in one's thinking, memory, perception, feeling and judgment resulting in changes in talk and behavior which appear to be deviant from previous personality or from the norms of community.
- These changes in behavior cause distress and suffering to the individual or others or both.
- Changes and the consequent distress cause disturbance in day-to-day activities, work and relationship with important others (social and vocational dysfunction).
EVOLUTION OF MENTAL HEALTH SERVICES AND TREATMENT
Historically, mental illness was viewed as a demonic possession, the influence of ancestral spirits, the result of violating a taboo or neglecting a cultural ritual and spiritual condemnation. As a result, the mentally ill were often starved, beaten, burnt, amputated and tortured in order to make the body an unsuitable place for the demon. Gradually, man began the quest for scientific knowledge and truth, which can be traced as follows:
- Pythagoras (580-510 BC) developed the concept that the brain is the seat of intellectual activity.
- Hippocrates (460 - 370 BC) described mental illness as hysteria, mania and depression.
- Plato (427 - 347 BC) identified the relationship between mind and body.
- Asciepiades, who is referred to as the Father of Psychiatry, made use of simple hygienic measures, diet, bath, massage in place of mechanical restraints.
- The Greeks were the first to study mental illness scientifically and separate the study of mind from religion. Aristotle, a Greek philosopher, emphasized on the release of repressed emotions for the effective treatment of mental illness. He suggested catharsis and music therapy for patients with melancholia.
- During the middle ages the mentally ill were not considered as outcasts, but as people to be helped. One of the great figures during this time was St. Augustine, who believed that although God acted directly in human affairs, people were responsible for their own actions.
- Renaissance in Europe (1300–1600 AD): This period represented the saddest chapter in the history of psychiatry when it was believed that demons were the cause of hallucinations, delusions and sexual activity, and the treatment was torture and even death.
Some Important Milestones
DEVELOPMENT OF MODERN PSYCHIATRIC NURSING
Psychiatric nursing in general arose from the need for hospitals to provide socially acceptable levels of care for patients.
Some Important Milestones
Over the years the professional psychiatric nursing role has grown in complexity. In contemporary psychiatric nursing practice the role includes the parameters of clinical competence, patient advocacy, fiscal responsibility, professional collaboration, social accountability, legal and ethical obligations.
Current Issues, Future Prospects and Challenges – India
- There is a lack of clearly enunciated definitions of the roles of professional psychiatric nurses.
- Greater emphasis should be given to encourage a master's degree in psychiatric nursing, so that nurses become pioneers in teaching non professionals and play active roles in specialized treatment modalities like behavior therapy, family therapy and individual and group counseling.
- To offer Diploma in psychiatric nursing courses in more colleges so that trained psychiatric nurses will be available for psychiatric units in general and district hospitals.
- To maintain the minimum standards of psychiatric nursing care in mental hospitals, the recommended psychiatric nurse:patient ratio as per the INC is 1:5 in non-teaching and 1:3 in teaching hospitals. High priority needs to be given to increase psychiatric nursing manpower at the diploma, masters and doctorate levels.
- There is a crucial need to create proper jobs at par with other professionals, particularly in the community. High priority must be given to fill vacant positions in educational institutions. This will facilitate adequate manpower development in psychiatric nursing.
- An integrated and co-ordinated role, both in service and training is essential in maintaining the quality and standard of psychiatric nursing.
- Unfortunately, most psychiatric centers do not have qualified psychiatric nurses, even today. High priority should be given to place qualified psychiatric nurses in counseling centers, community mental health and school mental health programs.
- The National Mental Health Program for India (1982) recommended the formation of a District Mental Health Team (DMHT) in order to decentralize mental health care at the district level, with two qualified psychiatric nurses and one psychiatrist.
- The role of the psychiatric nurse in the district mental health program is to provide care to the inpatients. The qualified psychiatric nurses will actively participate in decentralized training to professionals and non-professionals working at taluk and Primary Health Centres (PHCs). They will also supervise the task of multipurpose workers in mental health care delivery. They will assist psychiatrist in research activities in monitoring mental health care at district and PHC levels. Nurse's active participation in mental health education to the public will go a long way in creating public awareness in the care of individuals with various mental disorders.
PREVALENCE AND INCIDENCE OF MENTAL HEALTH PROBLEMS AND DISORDERS
The WHO declared the World Health Day theme for the year 2001 as “Mental Health: Stop Exclusion – Dare to Care”, in order to focus global public health attention on this relatively neglected problem. Information regarding the prevalence of mental disorders in India needs to be generated to establish a database for mental health planners to assess the status of mental health in the country. The Bhore Committee concluded that mental patients requiring institutional treatment would be 2 per 1000 in the country.
During the last two decades, many epidemiological studies have been conducted in India, which show that the prevalence of major psychiatric disorder is about the same all over the world. The prevalence reported from these studies range from the population of 18 to 207 per 1000 with the median 65.4 per 1000. Most of these patients live in rural areas remote from any modern mental health facilities. A large number of adult patients coming to the general OPD are diagnosed mentally ill. However, these patients are usually missed because either medical officer or general practitioner at the primary health care unit does not ask detailed mental health history. Due to the under-diagnosis of these patients, unnecessary investigations and treatments are offered which heavily cost to the health providers.
Analysis of fifteen epidemiological studies shows prevalence rates as follows (Ganguli HC, 2000) (Box 1.2).
According to health information of India 2005, mental morbidity rate is not less than 18–20/1000 and the types of illness and their prevalence are very much the same as in other parts of the world.
Analysis of 10 epidemiological studies shows prevalence rates as follows:
National prevalence rates for all mental disorders was 65.4/1000 population; with rural and urban rates of 64.4 and 66.4/1000 respectively. Thus the urban rate is marginally higher than the rural rate. The most widely prevalent disorders were observed to be depression and anxiety. The urban morbidity rate was observed to be 2 per 1000 higher than the rural morbidity rate. (Madhav MS 2001) (Box 1.3).
The common psychiatric illnesses encountered in a clinic of a General Hospital are—Neurotic disorders (for example, anxiety neurosis, obsessive-compulsive disorder and reactive depression), psychosomatic disorders (for example, hypertension, diabetes mellitus, peptic ulcer, tension headaches, etc.), functional psychosis (for example, schizophrenia, mania and depression and organic psychosis).
In a child guidance clinic, the common mental illnesses include mental retardation, conduct disorder, hyperkinetic syndrome, enuresis, etc.
In a geriatric clinic the common disorders are depression, dementia, delusional disorders, etc.
In a psychosexual clinic the common problems include Dhat syndrome, premature ejaculation, erectile impotence and so on.
The prevalence of psychiatric disorders is 58.2 per thousand which means that there are about 5.7 crore people suffering from some sort of psychiatric disturbance. Out of this 4 lakh people have organic psychosis, 26 lakh people have schizophrenia and 1.2 crore people have affective psychosis; thus there are about 1.5 crore people suffering from severe mental disorders, besides 12,000 patients in Government mental hospitals in the country (Reddy et al, 1996).
MENTAL HEALTH ACT
Indian Lunacy Act (ILA), act 4 of 1912, replaced the Indian Lunatic Asylums act, act 36 of 1858. It was enacted to govern reception, detention and care of lunatics and their property and to consolidate and amend the laws relating to lunacy.
The act was divided into 4 parts and 8 chapters consisting of 100 sections. The enactment of Indian Lunacy Act of 1912 was followed by opening of many new asylums, an improvement in the general conditions of asylums and an increase in awareness regarding the prevailing situation of lunatics in such asylums.
In 1946, the Bhore committee submitted its recommendations. The Indian psychiatric society, established in January 1947, was quick to react to the recommendations of Bhore committee. In January 1949, an adhoc drafting committee was appointed which consisted of 3 distinguished psychiatrists, they prepared a draft bill called as the “Indian Mental Health Act”, which was redrafted and finalized in January 1950 and forwarded to the Government of India. After 37 years the Mental Health Act (MHA) 1987 was finally passed by the Lok Sabha on 19th march 1987. Later, the Government of India issued orders that the act came into force with effect from April 1, 1993 in all the states and union territories of India. It is an “act to consolidate and amend the law relating to the treatment and care of mentally ill persons, to make better provision with respect to their property and affairs and for matters connected those with or incidental there to”. The Act is divided into 10 chapters consisting of 98 sections.
(Refer Chapter 14, for Indian Mental Health Act)
NATIONAL MENTAL HEALTH POLICY VIS-À-VIS NATIONAL HEALTH POLICY
National Mental Health Policy (NMHP-2001)
According to WHO, “Mental Health Policies describe the values, objectives and strategies of the Government to reduce the Mental Health burden and to improve mental health. They define a vision for the future that helps to establish a blueprint for the prevention and treatment of mental illness, the rehabilitation of people with mental disorders, and the promotion of mental health in the community. Policies specify the standards that need to be applied across all programs and services, linking them all with a common vision, objectives and purpose. Without this overall coordination, programs and services are likely to be inefficient and fragmented.”
The first draft of National Mental Health Policy (NMHP) was prepared in late 2001 and came into existence in 2003. The NMHP will provide the necessary conceptual framework for achieving goals. The NMHP is being energetically implemented, with adequate budgetary support in the 10th five year plan.
- The District Mental Health Program (DMHP) is redesigned around a nodal institution, where most instances will be the zonal medical college. School mental health programs and dementia care services may be gradually integrated with the DMHP.
- Strengthening the medical college psychiatry departments with a view to develop psychiatric manpower, improve psychiatric treatment facilities at secondary level and to promote the development of general psychiatric hospitals in order to reduce and eventually to eliminate, to a large extent the need for big mental hospitals with all their attendant infirmities.
- Streamlining and modernization of mental hospitals to transform them from the present, mainly custodial mode to tertiary care centers to excellence with a dynamic social orientation for providing leadership to Research and Development (R & D) in the field of community mental health.
- Strengthening of Central and State Mental Health Authorities in order that they may effectively fulfill their role of monitoring on-going mental health programs, determining priorities at the central/state level and promoting intersectoral collaboration and linkages with other national programs.
- Research and training aimed at building up an extensive database of epidemiological information relating to mental disorders and their course/outcome, development of better and more cost effective intervention models, promotion of intersectoral research and providing the necessary inputs/conceptual framework for health and policy planning.
- Focused Information Education and Communication (IEC) activities with the active collaboration of professional agencies such as the Indian Institute of Mass Communication and directed towards enhancing public awareness and eradicating the stigma/discrimination related to mental illness, will form an important component of this policy objective.
Tenth Five Year Plan (2002–2007)
- District mental health program will be extended to one district attached to each of the 100 medical colleges in the country, thereby covering 100 districts in the first phase, and there after expanding to 100 districts more in the second phase, thus making a total of 200 districts across the country.
- Strengthening of medical colleges with allocation of Rs. 50 lakhs each to 100 medical colleges, for upgrading departments of psychiatry.
- Streamlining and modernization of mental hospitals with the aim of reduction in chronicity through intensive therapeutic intervention using non-conventional anti-psychotic medication, promoting care of chronically mentally ill patients in the community using outreach maintenance modalities.
- Strengthening of Central and State Mental Health Authorities by facilitating the establishment of permanent secretaries and networking of state authorities with national level to ensure effective co-ordination in all areas of activity.
- IEC (Information, education, communication) training and research by sponsoring relevant community based research projects and building up an extensive data base which will form the basis for development of models and policy planning.
Eleventh Five Year Plan (2007–2012)
- The DMHP will be extended to another lot of 200 districts while consolidating same in 200 districts covered at the end of 10th plan.
- Qualitative as well as quantitative improvement will be introduced in the areas of research, training and IEC, with more focused attention on epidemiological catchment area surveys on a larger scale.
Twelfth Five Year Plan (2012–2017)
- The DMHP will be extended to the remaining 193 districts and the gains made in the previous plans will be consolidated, further upgradation of the psychiatric departments in medical colleges will be undertaken and 20 mental hospitals will be reconstructed.
- IEC activities will be augmented to cover all sections of the population across the whole country.
- Senior citizens suffering from severely disabling diseases such as Alzheimer's and other types of dementia, Parkinson's disease, depression of late onset and other psycho geriatric disorders.
- Victims of child sexual abuse, marital/domestic violence, dowry related ill treatment, rape and incest.
- Children and adolescents affected by problems of maladjustments or other scholastic problems, depression/psychosis of early onset, attention deficit hyper activity disorders and suicidal behavior resulting from failure in examination or other environmental stressors.
- Victims of poverty, destitution and abandonment, such as women thrown out of the marital home or old and infirm parents left to fend for themselves.
- Victims of natural or man-made disasters such as cyclones, earthquakes, famines, war, terrorism, communal/ethnic strife, with special attention to the specific needs of children orphaned by such disasters.
National Health Policy (NHP)
NHP was formulated in 1983 and revised in 2002.
The main objective of NHP-2002 is to achieve an acceptable standard of good health amongst the general population in the country. The approach would be to increase access to the decentralized public health system by establishing new infrastructure in deficient areas and by upgrading the infrastructure in the existing institutions.
Specific Recommendation with Regard to Mental Health
- Upgrading infrastructure of institutions at Central Government expense so as to secure the human rights of this vulnerable segment of society.
- Envisages a network of decentralized mental health services for ameliorating the more common categories of disorders.
Specific discussion regarding mental health
Mental health disorders are actually much more prevalent than is apparent on the surface. While such disorders do not contribute significantly to mortality, they have a serious bearing on the quality of life of the affected persons and their families. Sometimes, based on religious faith, mental disorders are treated as spiritual affliction. This has led to the establishment of unlicensed mental institutions as an adjunct to religious institutions where reliance is placed on faith cure. Serious conditions of mental disorder require hospitalization and treatment under trained supervision. Mental health institutions are woefully deficient in physical infrastructure and trained manpower. NHP-2002 will address itself to these deficiencies in the public health sector.
NATIONAL MENTAL HEALTH PROGRAM
The Government of India launched the National Mental Health Program (NMHP) in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it.
- Prevention and treatment of mental neurological disorders and their associated disabilities.
- Use of mental health technology to improve general health services.
- Application of mental health principles in total national development to improve quality of life.
- To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population.
- To encourage application of mental health knowledge in general health care and social development.
- To promote community participation in the mental health services development and to stimulate efforts towards self-help in the community.
- Integration of mental health with primary health care through the NMHP;
- Provision of tertiary care institutions for treatment of mental disorders;
- Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the central mental health authority, and state mental health authority.
- Integration of mental health care services with the existing general health services.
- Provision of appropriate task-oriented training to the existing health staff.
- Linkage of mental health services with the existing community development program.
I. Treatment: Multiple levels
- Village and Sub-center Level Multipurpose Workers (MPW) and Health Supervisors (HS), under the supervision of Medical Officer (MO) to be trained for:
- Management of psychiatric emergencies.
- Administration and supervision of maintenance treatment for chronic psychiatric disorders.
- Diagnosis and management of grandmal epilepsy, especially in children.
- Liaison with local school teachers and parents regarding mental retardation and behavioral problems in children.
- Counseling problems related to alcohol and drug abuse.
- MO of Primary Health Center (PHC) aided by HS, to be trained for:
- Supervision of MPW's performance.
- Elementary diagnosis.
- Treatment of functional psychosis.
- Treatment of uncomplicated cases of psychiatric disorders associated with physical diseases.
- Management of uncomplicated psychosocial problems.
- Epidemiological surveillance of mental morbidity.
- District hospital: It was recognized that there should be at least one psychiatrist attached to every district hospital as an integral part of the district health services. The district hospital should have 30–50 psychiatric beds. The psychiatrist in a district hospital was envisaged to devote only a part of his time to clinical care and a greater part in training and supervision of non-specialist health workers.
- Mental hospitals and teaching psychiatric units: Major activities of these higher centers of psychiatric care include:
- Help in care of ‘difficult’ cases.
- Specialized facilities like, occupational therapy units, psychotherapy, counseling and behavioral therapy.
The components of this sub-program include treatment of epileptics and psychotics at the community level and development of rehabilitation centers at both the district level and higher referral centers.
The prevention component is to be community-based, with initial focus on prevention and control of alcohol-related problems. Later on, problems like addictions, juvenile delinquency and acute adjustment problems like suicidal attempts are to be addressed.
MENTAL HEALTH TEAM OR MULTIDISCIPLINARY TEAM
Multidisciplinary approach refers to collaboration between members of different disciplines who provide specific services to the patient. The multidisciplinary team includes:
- A Psychiatrist
- A Psychiatric nurse
- A Clinical psychologist
- A Psychiatric social worker
- An Occupational therapist or an activity therapist
- A Pharmacist and a dietitian
- A Counselor
A Psychiatrist is a medical doctor with special training in psychiatry. He is accountable for the medical diagnosis and treatment of patient. Other important functions are:
- Admitting patient into acute care setting.
- Prescribing and monitoring psychopharmacologic agents.
- Administering electroconvulsive therapy.
- Conducting individual and family therapy.
- Participating in interdisciplinary team meetings.
- Owing to their legal power to prescribe and to write orders, psychiatrists often function as leaders of the team.
A Psychiatric nurse is a registered nurse with specialized training in the care and treatment of psychiatric patients; she may have a Diploma, MSc, MPhil or PhD in psychiatric nursing. She is accountable for the bio-psychosocial nursing care of patients and their milieu. Other functions include:
- Administering and monitoring medications.
- Assisting in numerous psychiatric and physical treatments.
- Participate in interdisciplinary team meetings.
- Teach patients and families.
- Take responsibility for patients' records.
- Act as patient's advocate.
- Interact with patients' significant others.
A Clinical psychologist should have a Masters Degree in Psychology or Ph.D in clinical psychology with specialized training in mental health settings. He is accountable for psychological assessments, testing, and treatments. He offers direct services such as individual, family or marital therapies.
A Psychiatric social worker should have a Masters Degree in Social Work or Ph.D degree with specialized training in mental health settings. He is accountable for family case work and community placement of patients. He conducts group therapy sessions. He emphasizes intervention with the patient in social environment in which he will live.
An Occupational therapist or an Activity therapist is accountable for recreational, occupational and activity programs. He assists the patients to gain skills that help them cope more effectively to gain or retain employment, to use leisure time.
A Counselor provides basic supportive counseling and assists in psychoeducational and recreational activities.
NATURE OF MENTAL HEALTH NURSING
Psychiatric nursing is a profession, possessing its unique history, ideology, knowledge and skills. It provides services to individuals whose primary health needs are related to mental, emotional and developmental problems, especially serious disorders and persistent disabilities. It is committed to the maintenance, promotion and restoration of optimal mental health for individuals, families, community groups and society through the use of therapeutic relationships and interventions.
Psychiatric nursing is a specialized area of nursing practice, employing the wide range of explanatory theories of human behavior as its science and purposeful use of self as its art. (American Nurses Association, 2000).
Psychiatric nursing is both an art and science. During actual practice, the art and the science of nursing are inextricable. The art of caring is professionally embodied in a therapeutic alliance that develops between the nurse and patient, and is referred to as the nurse patient relationship. The alliance is a vehicle for the patient to learn and practice skills for the purpose of gaining insight, effecting change, healing mental and emotional wounds and promoting growth.
The science of psychiatric nursing includes understanding and use of principles of nursing on all levels. In addition, there is required commitment to remain current in knowledge and to practice all learned skills and procedures that ensure patient safety and well being.
The Philosophical Beliefs of Psychiatric Nursing Practice
- The individual has intrinsic worth and dignity and each person is worthy of respect.
- Each person functions as a holistic being who acts on, interacts with and reacts to the environment as a whole person.
- All behavior of the individual is meaningful. It arises from personal needs and goals and can be understood only from the person's internal frame of reference and within the context in which it occurs.
- Behavior consists of perceptions, thoughts, feelings and actions.
- The goal of nursing care is to promote wellness, maximize integrated functioning and enhance self actualization.
- An interpersonal relationship can produce change and growth within the individual. It is the vehicle for application of nursing process and the attainment of the goal of nursing care.
- The psychiatric nurse uses knowledge from the psychosocial and biophysical sciences and theories of personality and human behavior. From these sources the nurse derives a theoretical framework on which to base the nursing practice.
SCOPE OF MENTAL HEALTH NURSING
The areas of concern for the psychiatric mental health nurse include a wide range of actual or potential mental health problems, such as emotional stress or crisis, self concept changes, developmental issues, physical symptoms that occur with psychological changes, and symptom management of patient with mental disorders. To understand the problem and select an appropriate intervention, integration of knowledge from the biological, psychological and social domain is necessary. Today the scope of mental health nursing is not restricted within the confines of the bedside nursing care. A mental health nurse needs to be skilled and clinically competent, sensitive to the social environment, the advocacy needs of the patients and their families as well as be aware of the legal and ethical dilemmas.
Current Issues and Trends in Care
A psychiatric nurse faces various challenges because of changes in the inpatient care approach. Some of these changes that affect her role are as follows:
Trends in Health Care
- Increased mental health problems
- Provision for quality and comprehensive services
- Multi-disciplinary team approach
- Providing continuity of care
- Care is provided in alternative settings
- Raised standard of living
Changes in Illness Orientation
- Shift from illness to prevention (modification of style), specific to holistic, quantity of care to quality of care.
Changes in Care Delivery
- Care delivery is shifted from institutional services to community services, genetic services to counseling services, nurse-patient relationship to nurse-patient partnership.
- Mass media
- Electronic systems
- Nursing informatics
- Increased consumer awareness.
- Awareness of the community in early detection and treatment of mental illness as well as proper utilization of available psychiatric hospitals.
- Patients are health care consumers demanding quality health care services at affordable cost with less restrictive and more humane rates.
- Bringing mental health patients out of the hospital and shifting care to community.
Physician Shortage and Gaps in Service
- Physician shortage can provide the opportunity for new roles for example, nurse practitioner. In respect to gaps in services, nurses always meet the needs of people for whom services are not available, for example, home visiting nurse.
- Increasing number of the elderly group.
- Type of family (increased number of nuclear families).
Change in needs of the Patients
- Wanting a more holistic orientation in health care.
Educational Programs for the Psychiatric Nurse
- Diploma in Psychiatric Nursing (The first program was offered in 1956 at NIMHANS, Bengaluru)
- MSc in Psychiatric Nursing (The first program was offered in 1976 at Rajkumari Amrit Kaur College of Nursing, New Delhi)
- MPhil in Psychiatric Nursing (1990, M.G. University, Kottayam).
- Doctorate in Psychiatric Nursing (offered at MAHE, Manipal; RAK College of Nursing, Delhi; NIMHANS, Bengaluru), National Consortium for PhD in Nursing under RGUHS, Karnataka, etc.
- Short-term training programs for both the degree and diploma holders in nursing.
Standards of Mental Health Nursing
The development of standards for nursing practice is a beginning step towards the attainment of quality nursing care. The adoption of standards helps to clarify nurses' areas of accountability, since the standards provide the nurse, the health agency, other professionals, patients, and the public, with a basis for evaluating practice. Standards also define the nursing profession's accountability to the public. These standards are therefore a means for improving the quality of care for mentally ill people.
Development of Code of Ethics
This is very important for a psychiatric nurse as she takes up independent roles in psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy, maintains patient's confidentiality, protects his rights and acts as patient's advocate.
Legal Aspects in Psychiatric Nursing
Knowledge of the legal boundaries governing psychiatric nursing practice is necessary to protect the public, the patient, and the nurse. The practice of psychiatric nursing is influenced by law, particularly in its concern for the rights of patients and the quality of care they receive.
The patient's right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality, and record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.
Promotion of Research in Mental Health Nursing
The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.
Cost Effective Nursing Care
Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.
Focus of Care
A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.
Roles of the Psychiatric-Mental Health Nurse in Contemporary Mental Health Care
Trends and issues in the health care system affect the roles of the psychiatric – mental health nurse. Although psychiatric nurses have traditionally worked on inpatient psychiatric units, they have continued to expand their role into the community.
There are two levels of psychiatric-mental health nurses: The generalist (registered psychiatric nurse) and the specialist (CNS). The scope and roles of both are guided by nurse practice acts and by standards of care.
Role of the Generalist
The psychiatric mental health generalist nurse is a licensed registered nurse for delivering primary mental health care. It incorporates both physical and mental health care. Generalist exercises a holistic approach to practice and performs psychiatric nursing in prevention programs, community and day treatment centers, psychiatric rehabilitation facilities, homeless shelters and many other settings.
Role of the Specialist
Psychiatric Clinical Nurse Specialist (CNS) holds a masters degree in psychiatric mental health nursing. CNS is an advanced practice nurse who is usually a primary health care provider, functions autonomously, often works in a semi-isolated situation, has medication prescription privileges (depending upon individual state laws), manages the overall care of people with emotional and psychiatric problems, and usually has a consultative arrangement with a psychiatrist. For example, the advanced practice nurses in Minnesota are psychotherapists, consultants, milieu specialists, role models, teachers, administrators, crisis intervention specialists and co-ordinators.
Community Mental Health Nurse (CMHN)
Community mental health nursing is the application of knowledge of psychiatric nursing in preventing mental illness, promoting and maintaining mental health of the people. It includes early diagnosis, appropriate referrals, care and rehabilitation of mentally ill people.
Psychiatric Home Care Nurse
Home health care is one aspect of community health nursing. Psychiatric home care nurses provide holistic psychiatric nursing care on a visiting basis to people needing assistance. These nurses provide comprehensive care, including psychiatric and physical assessment, direct nursing care, behavioral management crisis intervention, psychoeducation, in-home detoxification, medication management, case management and consultation with colleagues.
Forensic Psychiatric Nurse
Forensic nursing is a growing specialty in other countries around the globe, especially in the UK, Australia, Germany, Japan and Canada, and it is an expanded scope of practice. The forensic psychiatric nurse works with individuals who have mental health needs and who have entered the legal system. Nurses in this role perform physical and psychiatric assessment and develop plans of care for the patients entrusted to their care.
Psychiatric Consultation – Liaison Nurse (PCLN)
PCLN has arisen in response to the increased recognition of the importance of psycho-physiological inter-relationships and their impact on physical illness, recovery and wellness. It is an advanced practice nurse who practices psychiatric and mental health nursing in a medical setting/non-psychiatric setting providing consultation and education to patients, families, and health care team and the community. PCLN may provide assessment, recommendations and supportive therapy to patients who are anxious, depressed or experiencing other psychological problems or emotional distress.
Nurse case managers act as advocates for patients and their families by coordinating care and linking the patient with the physician, other members of the health-care team, resources and the payers (Fig. 1.1).
Factors that indicate the need for a nurse case manager include:
- A complex treatment plan that requires co-ordination
- An injury or illness that may permanently prevent the patient from returning to a previous level of health
- Pre-existing medical condition that may complicate or prolong recovery
- A need for assistance in accessing health-care resources
- Environmental stressors that may interfere with recovery
In the community, the case manager works with patients on a broad range of issues from accessing needed medical and psychiatric services to carrying out tasks of daily living such as using public transportation, managing money and buying groceries.
Case management can be provided by an individual or a team. It may include both face-to-face and telephone contact with the patient, as well as contact with other service providers. One of the most valuable assets case managers possess is their ability to synthesize patient data and act as conduits between patients and the health care system.
Geronursing is expanding the psychiatric nursing practice to aged people who have been affected by emotional and behavioral disorders such as dementia, chronic schizophrenia, delirium, etc.
Parish nursing is another area of expansion of psychiatric nurse role. Parish nursing is a program that promotes health and wellness of body, mind and spirit. The parish nurse is a pastorally called, spiritually mature, licensed registered nurse with a desire to serve the members and friends of his or her congregation. In 1998 the American Nursing Association recognized parish nursing as a specialty focusing on disease prevention and health promotion. It is a non-invasive type of nursing in which no hands-on nursing care is provided. Rather parish nurses are conduits of health information, support and social services. They evaluate the unique needs of various age groups within the congregation, including children, adults and the elderly. They serve as the community link between health institution and home by providing physical and mental health screenings, outreach education and visits to the home, hospital or long term care facility.
Telehealth / Telenurse
Nurses engaged in telenursing practice use technologies such as internet, computers, telephones, digital assessment tools and telemonitoring equipments to deliver nursing care. In India around 10 hospitals are having tele-medicine departments. For example, at Apollo hospitals, Narayana Hrudayalaya and Hosmat hospital at Bengaluru, job opportunities are available for tele-nurses. Chaithanya Medical Foundation, Bengaluru is providing tele-nursing education. IT companies are recruiting tele-health nurses in Hyderabad, Bengaluru and Chennai. For example: Infosys, Vivus, etc.
Nurse researchers are scientists who seek to find answers to questions through methodical observations and experimentation. They design studies, conduct research and disseminate findings at professional meets and in peer reviewed journals. They are doctorally or post-doctorally prepared persons who initiate or participate in all phases of the research process. They work in a variety of settings.
Psychiatric Nurse Educator
The psychiatric nurse educator works in educational institutions, staff development department of health care agencies, patient education department (teach the mentally ill patients and their families about care to provide at home). Another function of nurse educator is planning and changing the curriculum planning according to the needs of the society and learner.
Nurse Administrator / Manager
A nurse manager works less directly with patients, but has the responsibility to provide nursing leadership to ensure that an appropriate therapeutic milieu is maintained. A key responsibility is the support and development of nurses, representing nursing views to senior managers. Nurse Manager plays an important role in negotiating and allocating nursing resources within clinical directorates. Individuals, who assume a nurse executive role, typically hold a master's degree. They serve at all management levels in health care organizations and in the community.
Psychiatric nurse as collaborative member of the interdisciplinary team
Collaboration implies a commitment to common goals, with shared responsibility for the outcome of care. It also implies helping to facilitate the mental health of the patient, family or community within the context of the treatment team. Nurses bring their own specialized knowledge to the treatment process, thereby, enhancing information about the patient's assessment, treatment needs and progress. Seven characteristics of effective collaboration includes: trust, respect, commitment, co-operation, co-ordination, communication and flexibility.
One of the latest roles is that of the nurse psychopharmacologist – the psychiatric clinical nurse specialist with prescriptive authority.
The new opportunities for psychiatric nursing practice that are emerging throughout the continuum of mental health care are exciting for the speciality. They allow psychiatric nurses to demonstrate their flexibility, accountability, and self direction as they move forward into these expanding areas of practice. The expansion of mental health treatment settings is providing psychiatric nurses with the opportunity to implement primary, secondary and tertiary prevention functions from a holistic, biopsychosocial perspective, thus expanding their base of practice to better meet the mental health needs of individuals, families, groups and communities.
FUNCTIONS OF MENTAL HEALTH NURSE IN VARIOUS SETTINGS
Practice Setting for Psychiatric Nurses
For many years, the majority of mental health care was provided in the hospital setting. Since the 1970s, the trend has changed to treat patients in less restrictive or community based settings.
While traditional practice settings for psychiatric nurses are psychiatric hospitals, community mental health centers, psychiatric units in the general hospitals, residential treatment facilities and private clinics, more recently alternative treatment settings have emerged. These are partial hospitalization settings, day care centers, home care, out patient departments or ambulatory care centers. Community based treatment settings have expanded to group homes, hospice, care centers, crisis intervention centers, schools and universities, hospitals for the criminally insane, jails and prisons.
Functions of Psychiatric Nurse in Various Settings
Inpatient Psychiatric Ward
- Provide for environmental safety including protecting the patient and others from injury.
- Perform psychosocial, high risk and physical assessment.
- Promotion of self care activities.
- Medication management.
- Assisting for somatic therapies.
- Accurately observing and documenting the patient's behavior.
- Providing opportunities for the patient to make his own decisions and to assume responsibility for his life.
- Providing feedback to the patient based on observations of his behavior.
- Participation in various therapies, (psychotherapy, behavior therapy, group therapy, play therapy, family therapy, etc.) individual interactions, formal and informal group situations, role play, advocating on behalf of the patient and so forth.
- Delivering psycho-education.
- Counseling the patient and family members.
- Co-operating with other professionals in various aspects of the patients care; thereby, facilitating an interdisciplinary approach to care.
- Teaching social skills and stress management strategies.
- Discharge planning and community referral and follow up care.
- Supervise the work of subordinates.
- Maintain ward cleanliness.
Psychiatric Outpatient Department
- Performing clinical assessment.
- Assisting for psychometric assessment.
- Assisting or providing psychotherapy or behavior therapy.
- Counseling the patient and family members.
- Conducting group therapy.
- Delivering psychoeducation.
ECT Treatment Setting
- Teaching the patient prior to ECT treatment.
- Preparing the patient for ECT.
- Providing care during the procedure.
- Assisting with post treatment.
- Providing reassurance to reduce anxiety.
- Delivering psychoeducation regarding ECT.
Nurses who possess a masters degree in psychiatric nursing and are certified clinical nurse specialists may conduct individual or group psychotherapy.
- Establishing a therapeutic relationship with the patient.
- Providing an opportunity for the patient to release tension as problems are discussed.
- Assisting the patient in gaining insight about the problem.
- Providing opportunity to practice new skills.
- Reinforcing appropriate behavior as it occurs.
- Providing consistent emotional support.
Day Care Centers or Day Hospitals
In day treatment programs patients return home at night.
- Performing clinical assessment.
- Accurately observing and documenting the patient's behavior.
- Medication management.
- Teaching social skills.
- Counseling patient and family members.
- Delivering psychoeducation.
- Proving occupational or recreational therapy and vocational assistance.
Family therapy units
Psychiatric nurses' work with families at all levels of functioning.
- Assessing individual and family needs and resources.
- Facilitation of a family's use of positive coping strategies.
- Promote adaptive family functioning by teaching communication skills and problem solving skills.
- Delivering psychoeducation.
Child Psychiatric Ward
- Determine the child's strengths and abilities and develop a care plan to maintain and enhance capabilities.
- Monitor the child's developmental levels and initiate supportive interventions such as speech, language or occupational skills as needed.
- Provide a safe therapeutic environment, including protecting the child and others from injury.
- Co-operate with other professionals in an interdisciplinary approach to care.
- Provide adequate environmental stimulation.
- Teach the child adaptive skills such as eating, dressing, grooming and toileting.
- Demonstrate and help the child to practice self care skills.
- Provide genetic counseling if necessary.
- Deliver psychoeducation.
- Medication management.
- Provide emotional support to the parents.
- Participate in various therapies (behavior therapy, play therapy, expressive therapies, bibliotherapy, etc.)
- Assessment of symptoms.
- Teaching the patient and family regarding nutrition, exercise, hygiene and the relationship between physical and emotional health.
- Stress management.
- Daily living skills (basic money management, for example, bank accounts, rent, utility bills, use of the telephone, grocery shopping).
- Medication management – monitoring blood levels, signs and symptoms of overdose or toxicity, teaching on dosage, side effects and purposes.
- Administration of parenteral injections.
- Venipuncture for laboratory analysis.
- Act as a case manager and coordinate an array of services that include physical therapy, occupational therapy, social work and community services.
- Appropriate referrals to community agencies
- Provide supportive counseling and brief psychotherapy.
- Promotion of mental health and prevention of mental illnesses.
Community Mental Health Centers
- Identification of patients in the community.
- Refer the patients to appropriate hospitals.
- Home visiting and providing direct care to the patients in the community.
- Follow up care with special emphasis on medication regimen, improvement made and side effects, patient's occupational function.
- Conducting public awareness programs to remove misconceptions regarding mental disorders.
- Training of paraprofessional, community leaders, school teachers and other care giving professionals in the community.
- Management of resources planning and co-ordination.
- Direct services like, care of families at risk for violence, abuse and dysfunction, care of homeless mentally ill patients etc (Box 1.4).
Hospice Care Centers
- Helping cancer patients or terminally ill individuals through the grieving process.
- Provide supportive psychotherapy.
- Provide support groups for families of terminally ill patients.
- Crisis intervention during natural disasters, accidents, unexpected illnesses causing increased anxiety, stress or immobilization.
- Obstetric nursing centers.
- Providing support to bereaved parents in the event of fetal demise, abortion, birth of an infant with congenital abnormalities.
Medical Inpatient Wards
Psychosocial intervention for chronic illnesses with major psychological effects for example, Alzheimer's disease, HIV/AIDS, diabetes mellitus, Parkinson's disease, multiple sclerosis, hemophilia, colostomy, amputation, etc
Industrial Medical Centers
- Implementing or participating in industrial substance abuse programs for employees.
- Providing crisis intervention during accidents or the acute onset of a physical or mental illness (For example, heart attack).
- Teaching stress management.
Hospitals for Criminal Insane, Jails and Prisons
- Forensic psychiatric nurses assist patients with self care, administration of medications and monitor the effectiveness of the treatment.
- Promote coping skills.
- Advanced nurses are able to diagnose and treat individuals with psychiatric disorders and are allowed to prescribe medications.
- Provide psychotherapy and act as consultants.
- Forensic evaluation for legal sanity.
- Assessment of potential for violence.
- Parole/probation considerations.
- Assessment of racial/cultural factors during crime.
- Sexual predator screening and assessment.
- Competency therapy.
- Formal written reports to court.
- Review of police reports.
- On scene consultation to law enforcement.
FACTORS AFFECTING LEVEL OF NURSING PRACTICE
The level at which psychiatric nurses practice is determined by various factors such as:
- Nurse practice acts (Laws).
- Professional practice standards.
- Educational qualification and experience.
- Health care organization's philosophy.
- Self motivation and personal initiatives.
Nurse practice acts regulate entry into the profession and define the legal limits of nursing practice that must be adhered to by all nurses. Nurses must be familiar with the nurse practice act of their state and limit their practice accordingly.
Professional practice standards define nursing practice and performance; first developed by the ANA in 1973 and recently revised in 2000.
Nurses' qualifications include education, work experiences and certification status which determine the level of practice. The ANA has identified two levels of psychiatric nurses (Box 1.5).
A health care organization's philosophy of mental health and mental illness and its approach towards treatment help to share the expectations of both the nurse and patient.
The personal competence and initiative of the individual nurse determine one's interpretation of the nursing role and the success of its implementation. Other personal factors which influence the nurse's level of performance is – willingness to act as an agent of change, thorough knowledge of personal strength and weakness, realization of clinical competence.
CONCEPTS OF NORMAL AND ABNORMAL BEHAVIOR
Psychiatry as evident from the above is concerned with abnormal behavior in its broadest sense, but defining the concepts of normal and abnormal behavior as such has been found to be difficult. These concepts are much under the influence of socio-cultural factors.
Several models have been put forward in order to explain the concept of normal and abnormal behavior. Some of them are:
Medical model considers organic pathology as the definite cause for mental disorder. According to this model abnormal people are the ones who have disturbances in thought, perception and psychomotor activities. The normal are the ones who are free from these disturbances.
It involves the analysis of responses on a test or a questionnaire or observations of some particular behavioral variables. The degree of deviation from the standard norms arrived at statistically, characterizes the degree of abnormality.
Statistically normal mental health falls within two standard deviations (SDs) of the normal distribution curve.
The beliefs, norms, taboos and values of a society have to be accepted and adopted by individuals. Breaking any of these would be considered as abnormal. Normalcy is defined in context with social norms prescribed by the culture. Thus cultural background has to be taken into account when distinguishing between normal and abnormal behavior.
Behavior that is adaptive, is normal, maladaptive is abnormal. Abnormal behavior is a set of faulty behaviors acquired through learning.
- Write a note on development of modern psychiatric nursing.
- Write in detail about scope of psychiatric nursing.
- Describe various functions of mental health nurse in various settings.
- Components of mental health.
- Prevalence and incidence of mental health problems.
- Multidisciplinary team.
- Concepts of normal and abnormal behavior.
- Criteria for mental health.
- Characteristics of a mentally healthy person.
- Mental illness.
- Mental health.